Modulators of complement activity

ABSTRACT

The present disclosure relates to polypeptide modulators of complement activity, including cyclic polypeptide modulators. Included are methods of utilizing such modulators as therapeutics. Also provided are methods of measuring C5 and related complexes using C5 binding agents.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a 35 U.S.C. § 371 U.S. National Stage Entry ofInternational Application No. PCT/US2017/065005 filed Dec. 7, 2017,which claims the benefit of priority of U.S. Provisional PatentApplication No. 62/430,959 filed on Dec. 7, 2016 entitled “Modulators ofComplement Activity”, U.S. Provisional Application No. 62/491,702 filedon Apr. 28, 2017 entitled “Modulators of Complement Activity”, U.S.Provisional Application No. 62/525,284 filed on Jun. 27, 2017 entitled“Modulators of Complement Activity”, and U.S. Provisional ApplicationNo. 62/555,711 filed on Sep. 8, 2017 entitled “Modulators of ComplementActivity,” the contents of each of which are herein incorporated byreference in their entirety.

SEQUENCE LISTING

The instant application contains a Sequence Listing which has beensubmitted electronically in ASCII format and is hereby incorporated byreference in its entirety. Said ASCII copy, created on Jun. 3, 2019, isnamed 2011_1022US371_SL.txt and is 1,496 bytes in size.

BACKGROUND

The vertebrate immune response is comprised of adaptive and innateimmune components. While the adaptive immune response is selective forparticular pathogens and is slow to respond, components of the innateimmune response recognize a broad range of pathogens and respond rapidlyupon infection. One such component of the innate immune response is thecomplement system.

The complement system includes about 20 circulating complement componentproteins, synthesized primarily by the liver. Components of thisparticular immune response were first termed “complement” due to theobservation that they complemented the antibody response in thedestruction of bacteria. These proteins remain in an inactive form priorto activation in response to infection. Activation occurs by way of apathway of proteolytic cleavage initiated by pathogen recognition andleading to pathogen destruction. Three such pathways are known in thecomplement system and are referred to as the classical pathway, thelectin pathway, and the alternative pathway. The classical pathway isactivated when an IgG or IgM molecule binds to the surface of apathogen. The lectin pathway is initiated by the mannan-binding lectinprotein recognizing the sugar residues of a bacterial cell wall. Thealternative pathway remains active at low levels in the absence of anyspecific stimuli. While all three pathways differ with regard toinitiating events, all three pathways converge with the cleavage ofcomplement component C3. C3 is cleaved into two products termed C3a andC3b. Of these, C3b becomes covalently linked to the pathogen surfacewhile C3a acts as a diffusible signal to promote inflammation andrecruit circulating immune cells. Surface-associated C3b forms a complexwith other components to initiate a cascade of reactions among the latercomponents of the complement system. Due to the requirement for surfaceattachment, complement activity remains localized and minimizesdestruction to non-target cells.

Pathogen-associated C3b facilitates pathogen destruction in two ways. Inone pathway, C3b is recognized directly by phagocytic cells and leads toengulfment of the pathogen. In the second pathway, pathogen-associatedC3b initiates the formation of the membrane attack complex (MAC). In thefirst step, C3b complexes with other complement components to form theC5-convertase complex. Depending on the initial complement activationpathway, the components of this complex may differ. C5-convertase formedas the result of the classical complement pathway comprises C4b and C2ain addition to C3b. When formed by the alternative pathway,C5-convertase comprises two subunits of C3b as well as one Bb component.

Complement component C5 is cleaved by either C5-convertase complex intoC5a and C5b. C5a, much like C3a, diffuses into the circulation andpromotes inflammation, acting as a chemoattractant for inflammatorycells. C5b remains attached to the cell surface where it triggers theformation of the MAC through interactions with C6, C7, C8 and C9. TheMAC is a hydrophilic pore that spans the membrane and promotes the freeflow of fluid into and out of the cell, thereby destroying it.

An important component of all immune activity is the ability of theimmune system to distinguish between self and non-self cells. Pathologyarises when the immune system is unable to make this distinction. In thecase of the complement system, vertebrate cells express proteins thatprotect them from the effects of the complement cascade. This ensuresthat targets of the complement system are limited to pathogenic cells.Many complement-related disorders and diseases are associated withabnormal destruction of self cells by the complement cascade. In oneexample, subjects suffering from paroxysmal nocturnal hemoglobinuria(PNH) are unable to synthesize functional versions of the complementregulatory proteins CD55 and CD59 on hematopoietic stem cells. Thisresults in complement-mediated hemolysis and a variety of downstreamcomplications. Other complement-related disorders and diseases include,but are not limited to autoimmune diseases and disorders; neurologicaldiseases and disorders; blood diseases and disorders; and infectiousdiseases and disorders. Experimental evidence suggests that manycomplement-related disorders are alleviated through inhibition ofcomplement activity. Therefore, there is a need for compositions andmethods for selectively blocking complement-mediated cell destruction totreat related indications. The present invention meets this need byproviding related compositions and methods.

SUMMARY OF THE INVENTION

In some embodiments, the present disclosure provides a method oftreating paroxysmal nocturnal hemoglobinuria (PNH) in a subject, whereinthe subject has not been previously treated with eculizumab, the methodcomprising: administering R5000 to the subject at an initial loadingdose and administering R5000 to the subject at an initial treatmentdose, wherein the initial treatment dose is administered two or moretimes at regular intervals after the initial loading dose. Lactatedehydrogenase (LDH) levels in the subject may be monitored over thecourse of treatment. The initial treatment dose may be substituted witha modified treatment dose of R5000 after two weeks or more ofadministration with the initial treatment dose. The modified treatmentdose of R5000 may include an increased dose of R5000. The initialtreatment dose may be substituted with the modified treatment dose whensubject LDH levels are equal to or less than 1.5 times the upper limitnormal. The initial loading dose may include from about 0.1 mg/kg toabout 0.6 mg/kg R5000. The initial treatment dose may include from about0.1 mg/kg to about 0.3 mg/kg R5000. The initial treatment dose may besubstituted with a modified treatment dose of from about 0.3 mg/kg toabout 0.6 mg/kg R5000. Hemolysis in subject serum may be reduced. Noadverse events may be observed. At least one administration of R5000 mayinclude self-administration. The self-administration may be monitored.The self-administration may be remotely monitored. Theself-administration may be monitored using a smart device. The regularintervals may be from about every 12 hours to about every 168 hours.

Methods of the present disclosure may include a method of treating PNHin a subject, wherein the subject is currently under treatment witheculizumab or has previously received treatment with eculizumab, themethod including administering R5000 to the subject. Residual hemolyticactivity in the subject may be reduced or eliminated. Associationbetween C5 and alternative pathway C5-convertase may be inhibited. R5000may be co-administered with eculizumab. The subject may carry a C5polymorphism. The polymorphism may include p.Arg885His.

In some embodiments, the present disclosure provides a pharmaceuticalcomposition comprising R5001 and at least one pharmaceuticallyacceptable excipient. The at least one pharmaceutically acceptableexcipient may include at least one of sodium chloride and sodiumphosphate. The pharmaceutical composition may include from about 25 mMto about 100 mM sodium chloride. The pharmaceutical composition mayinclude from about 10 mM to about 100 mM sodium phosphate. R5001 may bepresent at a concentration of from about 1 mg/mL to about 400 mg/mL.

In some aspects, the present disclosure provides a method of treatingPNH in a subject, the method including administering a pharmaceuticalcomposition described herein. The subject may have been treatedpreviously with an antibody-based therapeutic. The subject may beresistant or unresponsive to treatment with the antibody-basedtherapeutic. The antibody-based therapeutic may be eculizumab. Thepharmaceutical composition may be administered at a dose of from about0.01 mg/kg to about 10 mg/kg. The pharmaceutical composition may beadministered at a dose of from about 0.1 mg/kg to about 0.3 mg/kg. Thepharmaceutical composition may be administered daily for at least twodays. The pharmaceutical composition may be administered daily for about12 weeks. The pharmaceutical composition may be administered daily forat least 1 year. The pharmaceutical composition may be administeredsubcutaneously or intravenously.

In some embodiments, the present disclosure provides a method ofinhibiting binding of C5 to alternative pathway C5 convertase bycontacting C5 with R5001. The C5 may be from a subject with a C5polymorphism. The C5 polymorphism may include p.Arg885His.

In some aspects, the present disclosure provides a method of inhibitingresidual C5 activity in a subject with PNH, wherein the subject iscurrently under treatment with eculizumab or has previously receivedtreatment with eculizumab, the method including administering R5000 tothe subject. Association between C5 and alternative pathwayC5-convertase may be inhibited. R5000 may be co-administered witheculizumab. The subject may carry a C5 polymorphism. The polymorphismmay include p.Arg885His.

In some embodiments, the present disclosure provides a method ofmeasuring C5 levels in a sample, the method including: immobilizing acapture agent on a substrate, wherein the capture agent binds to a siteon C5 that is distinct from the eculizumab binding site; contacting thesubstrate with the sample, wherein the immobilized capture agent bindsto C5 in the sample; contacting the substrate with a detection agent,wherein the detection agent binds to C5 bound to the immobilized captureagent; and measuring the level of bound detection agent as an indicatorof C5 levels in the sample. The detection agent may include a detectablelabel. The detection agent may be detected using a secondary detectionagent. The detection agent may include an anti-C5 antibody. Both free C5levels and eculizumab-associated C5 levels may be measured. Thesubstrate may be contacted with a second detection agent, wherein thesecond detection agent binds to eculizumab, and wherein the methodincludes measuring the level of bound second detection agent as anindicator of eculizumab-associated C5 levels. The second detection agentmay include a detectable label. The second detection agent may bedetected using a secondary detection agent. The capture agent mayinclude a variant of R5000. The R5000 variant may include an N-terminalbiotinylated PEG moiety and a substitution of the C-terminal lysine ofR5000 with norvaline in the R5000 variant.

Methods of the present disclosure may include a method of measuring freeeculizumab levels in a sample, the method including: immobilizing acapture agent on a substrate, wherein the capture agent binds to a siteon C5 that is distinct from the eculizumab binding site; contacting thesubstrate with an excess of C5 to form a C5-capture agent complex,wherein the C5-capture agent complex comprises immobilized C5;contacting the substrate with the sample, wherein the immobilized C5binds to eculizumab in the sample; contacting the substrate with adetection agent, wherein the detection agent binds to eculizumab; andmeasuring the level of bound detection agent as an indicator of freeeculizumab levels in the sample. The capture agent may include a variantof R5000. The R5000 variant may include an N-terminal biotinylated PEGmoiety and a substitution of the C-terminal lysine of R5000 withnorvaline in the R5000 variant. The detection agent may be an antibody.The detection agent may include a detectable label. The detection agentmay be detected using a secondary detection agent.

BRIEF DESCRIPTION OF THE FIGURES

The foregoing and other objects, features and advantages will beapparent from the following description of particular embodiments of theinvention, as well as the accompanying drawings illustrating theprinciples of various embodiments of the invention.

FIG. 1 is a scatter plot showing R5000 inhibition of C5a production.

FIG. 2 is a scatter plot showing R5000 inhibition of membrane attackcomplex formation.

FIG. 3 is a scatter plot showing R5000 inhibitor activity in aCynomolgus monkey model.

FIG. 4 is a scatter plot showing pharmacokinetic and pharmacodynamiccorrelation of R5000 in male Cynomolgus monkeys following multiplesubcutaneous administrations at 0.21 mg/kg.

FIG. 5 is a scatter plot showing pharmacokinetic and pharmacodynamiccorrelation of R5000 in male Cynomolgus monkeys following multiplesubcutaneous administrations at 4.2 mg/kg.

FIG. 6 is a line graph showing concentrations of R5000 in Cynomolgusmonkey after a first dose in a repeat-dose toxicology study.

FIG. 7 is a line graph showing concentrations of R5000 in Cynomolgusmonkey after the last dose in a repeat-dose toxicology study.

FIG. 8 is a graph showing predicted R5000 plasma concentrations in manwith daily dosing of R5000.

FIG. 9A is a graph showing R5000 dose-dependent maximum plasmaconcentration levels in a single-ascending-dose clinical study inhumans.

FIG. 9B is a graph showing plasma concentrations over time after singledose administration of R5000.

FIG. 10A is a graph showing percent hemolysis over time after singledose administration of R5000 over the duration of 4 days in humans.

FIG. 10B is a graph showing percent CH₅₀ over time after single doseadministration of R5000 in humans.

FIG. 10C is a graph showing percent hemolysis with various doses overthe duration of 28 days in humans.

FIG. 11 is a graph showing percent complement activity over time after asingle dose administration of R5000 in humans.

FIG. 12A is a graph showing changes in percent hemolysis in relation toR5000 concentration in a multi-dose human study.

FIG. 12B is a graph showing plasma concentrations of R5000 over time ina multi-dose human study.

FIG. 13A is a graph showing changes in complement activity over timewith R5000 treatment in a multi-dose human study.

FIG. 13B is a graph showing changes in complement activity over anextended period with R5000 treatment in a multi-dose human study.

FIG. 14 is a graph showing the predicted drug plasma concentration andhemolysis inhibition with R5000 in humans.

FIG. 15 is graph showing predicted pharmacokinetics and pharmacodynamicsof R5000 in humans.

FIG. 16A is a graph showing hemolysis in R5000 single dose cohorts ofhealthy human volunteers.

FIG. 16B is a graph showing predicted percent trough plasmaconcentrations with and without a loading dose of R5000.

FIG. 16C is a graph showing predicted hemolysis inhibition with 0.1mg/kg R5000 in humans.

FIG. 17 is a graph showing reduced hemolysis by mR5000 in patientsamples.

FIG. 18A is a graph showing percent hemolysis in patient samples overthe course of six weeks of treatment with R5000.

FIG. 18B is a graph showing changes in hemoglobin levels in patientsamples over the course of seven weeks of treatment with R5000.

FIG. 18C is a pair of graphs showing changes in patient lactatedehydrogenase (LDH) levels (individual and combined averages) over thecourse of seven weeks of treatment with R5000.

FIG. 18D is a graph showing levels of R5000 in patient samples over thecourse of six weeks of treatment with R5000.

FIG. 19 is a graph showing response units over time generated duringsurface plasmon resonance analysis of C5 inhibitor binding.

FIG. 20 is a graph showing percent hemolysis of PNH patient erythrocytesin the presence of R5000 or eculizumab.

FIG. 21 is a graph showing percent hemolysis of PNH patient erythrocytesin the presence of R5000 or eculizumab.

FIG. 22 is a graph showing percent hemolysis in erythrocytes carryingrecombinant C5 containing a known polymorphism p.Arg885His afterexposure to various concentrations of eculizumab or R5000.

FIG. 23 is a graph showing concentration of C5, C5:eculizumab, andeculizumab in PNH patient serum.

FIG. 24 is a graph showing percent residual hemolysis ineculizumab-treated PNH patient plasma in the presence of R5000 oradditional eculizumab.

DETAILED DESCRIPTION I. Compounds and Compositions

In some embodiments, the present disclosure provides compounds andcompositions which function to modulate complement activity. Suchcompounds and compositions may include inhibitors that block complementactivation. As used herein, “complement activity” includes theactivation of the complement cascade, the formation of cleavage productsfrom a complement component such as C3 or C5, the assembly of downstreamcomplexes following a cleavage event, or any process or event attendantto, or resulting from, the cleavage of a complement component, e.g., C3or C5. Complement inhibitors may include C5 inhibitors that blockcomplement activation at the level of complement component C5. C5inhibitors may bind C5 and prevent its cleavage, by C5 convertase, intothe cleavage products C5a and C5b. As used herein, “Complement componentC5” or “C5” is defined as a complex which is cleaved by C5 convertaseinto at least the cleavage products, C5a and C5b. “C5 inhibitors.”according to the invention, comprise any compound or composition thatinhibits the processing or cleavage of the pre-cleaved complementcomponent C5 complex or the cleavage products of the complementcomponent C5.

It is understood that inhibition of C5 cleavage prevents the assemblyand activity of the cytolytic membrane attack complex (MAC) onglycosylphosphatidylinositol (GPI) adherent protein-deficienterythrocytes. In some cases, C5 inhibitors presented herein may alsobind C5b, preventing C6 binding and subsequent assembly of the C5b-9MAC.

Peptide-Based Compounds

In some embodiments, C5 inhibitors of the present disclosure arepolypeptides. According to the present invention, any amino acid-basedmolecule (natural or unnatural) may be termed a “polypeptide” and thisterm embraces “peptides,” “peptidomimetics,” and “proteins.” “Peptides”are traditionally considered to range in size from about 4 to about 50amino acids. Polypeptides larger than about 50 amino acids are generallytermed “proteins.”

C5 inhibitor polypeptides may be linear or cyclic. Cyclic polypeptidesinclude any polypeptides that have as part of their structure one ormore cyclic features such as a loop and/or an internal linkage. In someembodiments, cyclic polypeptides are formed when a molecule acts as abridging moiety to link two or more regions of the polypeptide. As usedherein, the term “bridging moiety” refers to one or more components of abridge formed between two adjacent or non-adjacent amino acids,unnatural amino acids or non-amino acids in a polypeptide. Bridgingmoieties may be of any size or composition. In some embodiments,bridging moieties may comprise one or more chemical bonds between twoadjacent or non-adjacent amino acids, unnatural amino acids, non-aminoacid residues or combinations thereof. In some embodiments, suchchemical bonds may be between one or more functional groups on adjacentor non-adjacent amino acids, unnatural amino acids, non-amino acidresidues or combinations thereof. Bridging moieties may include one ormore of an amide bond (lactam), disulfide bond, thioether bond, aromaticring, triazole ring, and hydrocarbon chain. In some embodiments,bridging moieties include an amide bond between an amine functionalityand a carboxylate functionality, each present in an amino acid,unnatural amino acid or non-amino acid residue side chain. In someembodiments, the amine or carboxylate functionalities are part of anon-amino acid residue or unnatural amino acid residue.

C5 inhibitor polypeptides may be cyclized through the carboxy terminus,the amino terminus, or through any other convenient point of attachment,such as, for example, through the sulfur of a cysteine (e.g., throughthe formation of disulfide bonds between two cysteine residues in asequence) or any side-chain of an amino acid residue. Further linkagesforming cyclic loops may include, but are not limited to, maleimidelinkages, amide linkages, ester linkages, ether linkages, thiol etherlinkages, hydrazone linkages, or acetamide linkages.

In some embodiments, cyclic C5 inhibitor polypeptides of the inventionare formed using a lactam moiety. Such cyclic polypeptides may beformed, for example, by synthesis on a solid support Wang resin usingstandard Fmoc chemistry. In some cases, Fmoc-ASP(allyl)-OH andFmoc-LYS(alloc)-OH are incorporated into polypeptides to serve asprecursor monomers for lactam bridge formation.

C5 inhibitor polypeptides of the invention may be peptidomimetics. A“peptidomimetic” or “polypeptide mimetic” is a polypeptide in which themolecule contains structural elements that are not found in naturalpolypeptides (i.e., polypeptides comprised of only the 20 proteinogenicamino acids). In some embodiments, peptidomimetics are capable ofrecapitulating or mimicking the biological action(s) of a naturalpeptide. A peptidomimetic may differ in many ways from naturalpolypeptides, for example through changes in backbone structure orthrough the presence of amino acids that do not occur in nature. In somecases, peptidomimetics may include amino acids with side chains that arenot found among the known 20 proteinogenic amino acids,non-polypeptide-based bridging moieties used to effect cyclizationbetween the ends or internal portions of the molecule; substitutions ofthe amide bond hydrogen moiety by methyl groups (N-methylation) or otheralkyl groups; replacement of a peptide bond with a chemical group orbond that is resistant to chemical or enzymatic treatments; N- andC-terminal modifications; and/or conjugation with a non-peptidicextension (such as polyethylene glycol, lipids, carbohydrates,nucleosides, nucleotides, nucleoside bases, various small molecules, orphosphate or sulfate groups).

As used herein, the term “amino acid” includes the residues of thenatural amino acids as well as unnatural amino acids. The 20 naturalproteinogenic amino acids are identified and referred to herein byeither the one-letter or three-letter designations as follows: asparticacid (Asp:D), isoleucine (Ile:I), threonine (Thr:T), leucine (Leu:L),serine (Ser:S), tyrosine (Tyr:Y), glutamic acid (Glu:E), phenylalanine(Phe:F), proline (Pro:P), histidine (His:H), glycine (Gly:G), lysine(Lys:K), alanine (Ala:A), arginine (Arg:R), cysteine (Cys:C), tryptophan(Trp:W), valine (Val:V), glutamine (Gln:Q) methionine (Met:M),asparagine (Asn:N). Naturally occurring amino acids exist in theirlevorotary (L) stereoisomeric forms. Amino acids referred to herein areL-stereoisomers except where otherwise indicated. The term “amino acid”also includes amino acids bearing a conventional amino protecting group(e.g. acetyl or benzyloxycarbonyl), as well as natural and unnaturalamino acids protected at the carboxy terminus (e.g., as a (C1-C6) alkyl,phenyl or benzyl ester or amide; or as an alpha-methylbenzyl amide).Other suitable amino and carboxy protecting groups are known to thoseskilled in the art (See for example, Greene, T. W.; Wutz, P. G. M.,Protecting Groups In Organic Synthesis; second edition, 1991. New York,John Wiley & sons, Inc., and documents cited therein, the contents ofeach of which are herein incorporated by reference in their entirety).Polypeptides and/or polypeptide compositions of the present inventionmay also include modified amino acids.

“Unnatural” amino acids have side chains or other features not presentin the 20 naturally-occurring amino acids listed above and include, butare not limited to: N-methyl amino acids, N-alkyl amino acids, alpha,alpha substituted amino acids, beta-amino acids, alpha-hydroxy aminoacids. D-amino acids, and other unnatural amino acids known in the art(See, e.g., Josephson et al., (2005) J. Am. Chem. Soc. 127: 11727-11735;Forster, A. C. et al. (2003) Proc. Natl. Acad. Sci. USA 100: 6353-6357;Subtelny et al., (2008) J. Am. Chem. Soc. 130: 6131-6136; Hartman, M. C.T. et al. (2007) PLoS ONE 2:e972; and Hartman et al., (2006) Proc. Natl.Acad. Sci. USA 103:4356-4361). Further unnatural amino acids useful forthe optimization of polypeptides and/or polypeptide compositions of thepresent invention include, but are not limited to1,2,3,4-tetrahydroisoquinoline-1-carboxylic acid,1-amino-2,3-hydro-1H-indene-1-carboxylic acid, homolysine, homoarginine,homoserine, 2-aminoadipic acid, 3-aminoadipic acid, beta-alanine,aminopropionic acid, 2-aminobutyric acid, 4-aminobutyric acid,5-aminopentanoic acid, 5-aminohexanoic acid, 6-aminocaproic acid,2-aminoheptanoic acid, 2-aminoisobutyric acid, 3-aminoisobutyric acid,2-aminopimelic acid, desmosine, 2,3-diaminopropionic acid,N-ethylglycine. N-ethylasparagine, homoproline, hydroxylysine,allo-hydroxylysine, 3-hydroxyproline, 4-hydroxyproline, isodesmosine,allo-isoleucine. N-methylpentylglycine, naphthylalanine, omithine,pentylglycine, thioproline, norvaline, tert-butylglycine, phenylglycine,azatryptophan, 5-azatryptophan, 7-azatryptophan, 4-fluorophenylalanine,penicillamine, sarcosine, homocysteine, 1-aminocyclopropanecarboxylicacid, 1-aminocyclobutanecarboxylic acid, 1-aminocyclopentanecarboxylicacid, 1-aminocyclohexanecarboxylic acid,4-aminotetrahydro-2H-pyran-4-carboxylic acid,(S)-2-amino-3-(1H-tetrazol-5-yl)propanoic acid, cyclopentylglycine,cyclohexylglycine, cyclopropylglycine, η-ω-methyl-arginine,4-chlorophenylalanine, 3-chlorotyrosine, 3-fluorotyrosine,5-fluorotryptophan, 5-chlorotryptophan, citrulline,4-chloro-homophenylalanine, homophenylalanine,4-aminomethyl-phenylalanine, 3-aminomethyl-phenylalanine, octylglycine,norleucine, tranexamic acid, 2-amino pentanoic acid, 2-amino hexanoicacid, 2-amino heptanoic acid, 2-amino octanoic acid, 2-amino nonanoicacid, 2-amino decanoic acid, 2-amino undecanoic acid, 2-amino dodecanoicacid, aminovaleric acid, and 2-(2-aminoethoxy)acetic acid, pipecolicacid, 2-carboxy azetidine, hexafluoroleucine, 3-Fluorovaline,2-amino-4,4-difluoro-3-methylbutanoic acid, 3-fluoro-isoleucine,4-fluoroisoleucine, 5-fluoroisoleucine, 4-methylphenylglycine,4-ethyl-phenylglycine, 4-isopropyl-phenylglycine.(S)-2-amino-5-azidopentanoic acid (also referred to herein as “X02”),(S)-2-aminohept-6-enoic acid (also referred to herein as “X30”),(S)-2-aminopent-4-ynoic acid (also referred to herein as “X31”),(S)-2-aminopent-4-enoic acid (also referred to herein as “X12”),(S)-2-amino-5-(3-methylguanidino) pentanoic acid,(S)-2-amino-3-(4-(aminomethyl)phenyl)propanoic acid,(S)-2-amino-3-(3-(aminomethyl)phenyl)propanoic acid,(S)-2-amino-4-(2-aminobenzo[d]oxazol-5-yl)butanoic acid, (S)-leucinol,(S)-valinol, (S)-tert-leucinol, (R)-3-methylbutan-2-amine,(S)-2-methyl-1-phenylpropan-1-amine, and(S)—N,2-dimethyl-1-(pyridin-2-yl)propan-1-amine,(S)-2-amino-3-(oxazol-2-yl)propanoic acid,(S)-2-amino-3-(oxazol-5-yl)propanoic acid,(S)-2-amino-3-(1,3,4-oxadiazol-2-yl)propanoic acid,(S)-2-amino-3-(0,2,4-oxadiazol-3-yl)propanoic acid,(S)-2-amino-3-(5-fluoro-1H-indazol-3-yl)propanoic acid, and(S)-2-amino-3-(1H-indazol-3-yl)propanoic acid,(S)-2-amino-3-(oxazol-2-yl)butanoic acid, (S)-2-amino-3-(oxazol-5-yl)butanoic acid, (S)-2-amino-3-(1,3,4-oxadiazol-2-yl) butanoic acid,(S)-2-amino-3-(1,2,4-oxadiazol-3-yl) butanoic acid,(S)-2-amino-3-(5-fluoro-1H-indazol-3-yl) butanoic acid, and(S)-2-amino-3-(1H-indazol-3-yl) butanoic acid, 2-(2′MeOphenyl)-2-aminoacetic acid, tetrahydro 3-isoquinolinecarboxylic acid and stereoisomersthereof (including, but not limited, to D and L isomers).

Additional unnatural amino acids that are useful in the optimization ofpolypeptides or polypeptide compositions of the invention include butare not limited to fluorinated amino acids wherein one or more carbonbound hydrogen atoms are replaced by fluorine. The number of fluorineatoms included can range from 1 up to and including all of the hydrogenatoms. Examples of such amino acids include but are not limited to3-fluoroproline, 3,3-difluoroproline, 4-fluoroproline,4,4-difluoroproline, 3,4-difluroproline, 3,3,4,4-tetrafluoroproline,4-fluorotryptophan, 5-flurotryptophan, 6-fluorotryptophan,7-fluorotryptophan, and stereoisomers thereof.

Further unnatural amino acids that are useful in the optimization ofpolypeptides of the invention include but are not limited to those thatare disubstituted at the α-carbon. These include amino acids in whichthe two substituents on the α-carbon are the same, for example α-aminoisobutyric acid, and 2-amino-2-ethyl butanoic acid, as well as thosewhere the substituents are different, for example α-methylphenylglycineand α-methylproline. Further the substituents on the α-carbon may betaken together to form a ring, for example 1-aminocyclopentanecarboxylicacid, 1-aminocyclobutanecarboxylic acid, 1-aminocyclohexanecarboxylicacid, 3-aminotetrahydrofuran-3-carboxylic acid,3-aminotetrahydropyran-3-carboxylic acid,4-aminotetrahydropyran-4-carboxylic acid,3-aminopyrrolidine-3-carboxylic acid, 3-aminopiperidine-3-carboxylicacid, 4-aminopiperidinnne-4-carboxylix acid, and stereoisomers thereof.

Additional unnatural amino acids that are useful in the optimization ofpolypeptides or polypeptide compositions of the invention include butare not limited to analogs of tryptophan in which the indole ring systemis replaced by another 9 or 10 membered bicyclic ring system comprising0, 1, 2, 3 or 4 heteroatoms independently selected from N, O, or S. Eachring system may be saturated, partially unsaturated, or fullyunsaturated. The ring system may be substituted by 0, 1, 2, 3, or 4substituents at any substitutable atom. Each substituent may beindependently selected from H, F, Cl, Br, CN, COOR, CONRR′, oxo, OR,NRR′. Each R and R′ may be independently selected from H, C1-C20 alkyl,or C1-C20 alkyl-O—C1-20 alkyl.

In some embodiments, analogs of tryptophan (also referred to herein as“tryptophan analogs”) may be useful in the optimization of polypeptidesor polypeptide compositions of the invention. Tryptophan analogs mayinclude, but are not limited to 5-fluorotryptophan [(5-F)W],5-methyl-O-tryptophan [(5-MeO)W], 1-methyltryptophan [(1-Me-W) or(1-Me)W], D-tryptophan (D-Trp), azatryptophan (including, but notlimited to 4-azatryptophan, 7-azatryptophan and 5-azatryptophan)5-chlorotryptophan, 4-fluorotryptophan, 6-fluorotryptophan,7-fluorotryptophan, and stereoisomers thereof. Except where indicated tothe contrary, the term “azatryptophan” and its abbreviation, “azaTrp,”as used herein, refer to 7-azatryptophan.

Modified amino acid residues useful for the optimization of polypeptidesand/or polypeptide compositions of the present invention include, butare not limited to those which are chemically blocked (reversibly orirreversibly); chemically modified on their N-terminal amino group ortheir side chain groups; chemically modified in the amide backbone, asfor example, N-methylated, D (unnatural amino acids) and L (naturalamino acids) stereoisomers; or residues wherein the side chainfunctional groups are chemically modified to another functional group.In some embodiments, modified amino acids include without limitation,methionine sulfoxide; methionine sulfone; aspartic acid-(beta-methylester), a modified amino acid of aspartic acid; N-ethylglycine, amodified amino acid of glycine; alanine carboxamide; and/or a modifiedamino acid of alanine. Unnatural amino acids may be purchased fromSigma-Aldrich (St. Louis, Mo.), Bachem (Torrance, Calif.) or othersuppliers. Unnatural amino acids may further include any of those listedin Table 2 of US patent publication US 2011/0172126, the contents ofwhich are incorporated herein by reference in their entirety.

The present invention contemplates variants and derivatives ofpolypeptides presented herein. These include substitutional,insertional, deletional, and covalent variants and derivatives. As usedherein, the term “derivative” is used synonymously with the term“variant” and refers to a molecule that has been modified or changed inany way relative to a reference molecule or starting molecule.

Polypeptides of the invention may include any of the followingcomponents, features, or moieties, for which abbreviations used hereininclude: “Ac” and “NH2” indicate acetyl and amidated termini,respectively; “Nvl” stands for norvaline; “Phg” stands forphenylglycine; “Tbg” stands for tert-butylglycine; “Chg” stands forcyclohexylglycine; “(N-Me)X” stands for the N-methylated form of theamino acid indicated by the letter or three letter amino acid code inplace of variable “X” written as N-methyl-X [e.g. (N-Me)D or (N-Me)Aspstand for the N-methylated form of aspartic acid or N-methyl-asparticacid]; “azaTrp” stands for azatryptophan “(4-F)Phe” stands for4-fluorophenylalanine; “Tyr(OMe)” stands for O-methyl tyrosine, “Aib”stands for amino isobutyric acid; “(homo)F” or “(homo)Phe” stands forhomophenylalanine; “(2-OMe)Phg” refers to 2-O-methylphenylglycine;“(5-F)W” refers to 5-fluorotryptophan; “D-X” refers to theD-stereoisomer of the given amino acid “X” [e.g. (D-Chg) stands forD-cyclohexylglycine]; “(5-MeO)W” refers to 5-methyl-O-tryptophan;“homoC” refers to homocysteine; “(1-Me-W)” or “(1-Me)W” refers to1-methyltryptophan; “Nle” refers to norleucine; “Tiq” refers to atetrahydroisoquinoline residue; “Asp(T)” refers to(S)-2-amino-3-(1H-tetrazol-5-yl)propanoic acid; “(3-Cl-Phe)” refers to3-chlorophenylalanine; “[(N-Me-4-F)Phe]” or “(N-Me-4-F)Phe” refers toN-methyl-4-fluorophenylalanine; “(m-Cl-homo)Phe” refers to meta-chlorohomophenylalanine; “(des-amino)C” refers to 3-thiopropionic acid;“(alpha-methyl)D” refers to alpha-methyl L-aspartic acid; “2Nal” refersto 2-naphthylalanine; “(3-aminomethyl)Phe” refers to3-aminomethyl-L-phenyalanine; “Cle” refers to cycloleucine; “Ac-Pyran”refers to 4-amino-tetrahydro-pyran-4-carboxylic acid; “(Lys-C16)” refersto N-ε-palmitoyl lysine; “(Lys-C12)” refers to N-ε-lauryl lysine;“(Lys-C10)” refers to N-ε-capryl lysine; “(Lys-C8)” refers toN-ε-caprylic lysine; “[xXylyl(y,z)]” refers to the xylyl bridging moietybetween two thiol containing amino acids where x may be m, p or o toindicate the use of meta-, para- or ortho-dibromoxlenes (respectively)to generate bridging moieties and the numerical identifiers, y and z,place the amino acid position within the polypeptide of the amino acidsparticipating in the cyclization; “[cyclo(y,z)]” refers to the formationof a bond between two amino acid residues where the numericalidentifiers, y and z, place the position of the residues participatingin the bond; “[cyclo-olefinyl(y,z)]” refers to the formation of a bondbetween two amino acid residues by olefin metathesis where the numericalidentifiers, y and z, place the position of the residues participatingin the bond; “[cyclo-thioalkyl(y,z)]” refers to the formation of athioether bond between two amino acid residues where the numericalidentifiers, y and z, place the position of the residues participatingin the bond; “[cyclo-triazolyl(y,z)]” refers to the formation of atriazole ring between two amino acid residues where the numericalidentifiers, y and z, place the position of the residues participatingin the bond. “B20” refers to N-ε-(PEG2-γ-glutamicacid-N-α-octadecanedioic acid) lysine [also known as(1S,28S)-1-amino-7,16,25,30-tetraoxo-9,12,18,21-tetraoxa-6,15,24,29-tetraazahexatetracontane-1,28,46-tricarboxylicacid.]

B20

“B28” refers to N-ε-(PEG24-γ-glutamic acid-N-α-hexadecanoyl)lysine.

B28

“K14” refers toN-ε-1-(4,4-dimethyl-2,6-dioxocyclohex-1-ylidene)-3-methylbutyl-L-lysine.All other symbols refer to the standard one-letter amino acid code.

Some C5 inhibitor polypeptides comprise from about 5 amino acids toabout 10 amino acids, from about 6 amino acids to about 12 amino acids,from about 7 amino acids to about 14 amino acids, from about 8 aminoacids to about 16 amino acids, from about 10 amino acids to about 18amino acids, from about 12 amino acids to about 24 amino acids, or fromabout 15 amino acids to about 30 amino acids. In some cases, C5inhibitor polypeptides comprise at least 30 amino acids.

Some C5 inhibitors of the invention include a C-terminal lipid moiety.Such lipid moieties may include fatty acyl groups (e.g., saturated orunsaturated fatty acyl groups). In some cases, the fatty acyl group maybe a palmitoyl group.

C5 inhibitors having fatty acyl groups may include one or more molecularlinkers joining the fatty acids to the peptide. Such molecular linkersmay include amino acid residues. In some cases, L-γ glutamic acidresidues may be used as molecular linkers. In some cases, molecularlinkers may include one or more polyethylene glycol (PEG) linkers. PEGlinkers of the invention may include from about 1 to about 5, from about2 to about 10, from about 4 to about 20, from about 6 to about 24, fromabout 8 to about 32, or at least 32 PEG units.

C5 inhibitors of the invention may have molecular weights of from about200 g/mol to about 600 g/mol, from about 500 g/mol to about 2000 g/mol,from about 1000 g/mol to about 5000 g/mol, from about 3000 g/mol toabout 4000 g/mol, from about 2500 g/mol to about 7500 g/mol, from about5000 g/mol to about 10000 g/mol, or at least 10000 g/mol.

In some embodiments, C5 inhibitor polypeptides of the invention includeR5000. The core amino acid sequence of R5000([cyclo(1,6)]Ac-K-V-E-R-F-D-(N-Me)D-Tbg-Y-azaTrp-E-Y—P-Chg-K; SEQ IDNO: 1) comprises 15 amino acids (all L-amino acids), including 4unnatural amino acids [N-methyl-aspartic acid or “(N-Me)D”,tert-butylglycine or “Tbg”, 7-azatryptophan or “azaTrp”, andcyclohexylglycine or “Chg” ]; a lactam bridge between K1 and D6 of thepolypeptide sequence, and a C-terminal lysine reside with a modifiedside chain, forming a N-ε-(PEG24-γ-glutamic acid-N-α-hexadecanoyl)lysineresidue (also referred to herein as “B28”). The C-terminal lysine sidechain modification includes a polyethyleneglycol (PEG) spacer (PEG24),with the PEG24 being attached to an L-γ glutamic acid residue that isderivatized with a palmitoyl group.

In some embodiments, the present invention includes variants of R5000.In some R5000 variants, the C-terminal lysine side chain moiety may bealtered. In some cases, the PEG24 spacer (having 24 PEG subunits) of theC-terminal lysine side chain moiety may include fewer or additional PEGsubunits. In other cases, the palmitoyl group of the C-terminal lysineside chain moiety may be substituted with another saturated orunsaturated fatty acid. In further cases, the L-γ glutamic acid linkerof the C-terminal lysine side chain moiety (between PEG and acyl groups)may be substituted with an alternative amino acid or non-amino acidlinker.

In some embodiments, C5 inhibitors may include active metabolites orvariants of R5000. Metabolites may include R5001. As used herein theterm “R5001” refers to a variant of R5000 with w-hydroxylation of thepalmitoyl tail. R5001 may be synthesized or may be formed byhydroxylation of an R5000 precursor. R5001 may be capable of binding toC5 with an equilibrium dissociation constant (K_(D)) equal to or similarto that of R5000 binding to C5 (e.g., about ±20% of the K_(D) of R5000binding to C5). R5001 may be capable of inhibiting C5 cleavage and/orblocking one or more downstream events associated with C5 cleavage witha half maximal inhibitory concentration (IC₅₀) equal to or similar tothat of R5000 (e.g., ±20% of the IC₅₀ of R5000 for inhibiting C5cleavage). R5001 may be capable of inhibiting complement-dependenthemolysis with an IC₅₀ equal to or similar to that of R5000 (e.g., about±20% of the IC₅₀ of R5000 for inhibiting hemolysis).

In some embodiments, R5000 variants may include modifications to thecore polypeptide sequence in R5000 that may be used in combination withone or more of the cyclic or C-terminal lysine side chain moietyfeatures of R5000. Such variants may have at least 50%, at least 55%, atleast 65%, at least 70%, at least 80%, at least 85%, at least 90%, or atleast 95% sequence identity to the core polypeptide sequence of (SEQ IDNO: 1).

In some cases, R5000 variants may be cyclized by forming lactam bridgesbetween amino acids other than those used in R5000.

C5 inhibitors of the invention may be developed or modified to achievespecific binding characteristics. Inhibitor binding may be assessed bydetermining rates of association and/or dissociation with a particulartarget. In some cases, compounds demonstrate strong and rapidassociation with a target combined with a slow rate of dissociation. Insome embodiments, C5 inhibitors of the invention demonstrate strong andrapid association with C5. Such inhibitors may further demonstrate slowrates of dissociation with C5.

C5 inhibitors of the invention that bind to C5 complement protein, maybind to C5 complement protein with an equilibrium dissociation constant(K_(D)) of from about 0.001 nM to about 0.01 nM, from about 0.005 nM toabout 0.05 nM, from about 0.01 nM to about 0.1 nM, from about 0.05 nM toabout 0.5 nM, from about 0.1 nM to about 1.0 nM, from about 0.5 nM toabout 5.0 nM, from about 2 nM to about 10 nM, from about 8 nM to about20 nM, from about 15 nM to about 45 nM, from about 30 nM to about 60 nM,from about 40 nM to about 80 nM, from about 50 nM to about 100 nM, fromabout 75 nM to about 150 nM, from about 100 nM to about 500 nM, fromabout 200 nM to about 800 nM, from about 400 nM to about 1,000 nM or atleast 1,000 nM.

In some embodiments, C5 inhibitors of the invention block the formationor generation of C5a from C5. In some case, formation or generation ofC5a is blocked following activation of the alternative pathway ofcomplement activation. In some cases, C5 inhibitors of the inventionblock the formation of the membrane attack complex (MAC). Such MACformation inhibition may be due to C5 inhibitor binding to C5b subunits.C5 inhibitor binding to C5b subunits may prevent C6 binding, resultingin blockage of MAC formation. In some embodiments, this MAC formationinhibition occurs after activation of the classical, alternative, orlectin pathways.

C5 inhibitors of the invention may be synthesized using chemicalprocesses. In some cases, such synthesis eliminates risks associatedwith the manufacture of biological products in mammalian cell lines. Insome cases, chemical synthesis may be simpler and more cost-effectivethan biological production processes.

In some embodiments, C5 inhibitor (e.g., R5000 and/or an activemetabolite or variant thereof) compositions may be pharmaceuticalcompositions comprising at least one pharmaceutically acceptableexcipient. In some embodiments, the pharmaceutically acceptableexcipient may include at least one of a salt and a buffering agent. Thesalt may be sodium chloride. The buffering agent may be sodiumphosphate. Sodium chloride may be present at a concentration of fromabout 0.1 mM to about 1000 mM. In some cases, sodium chloride may bepresent at a concentration of from about 25 mM to about 100 mM. Sodiumphosphate may be present at a concentration of from about 0.1 mM toabout 1000 mM. In some cases, sodium phosphate is present at aconcentration of from about 10 mM to about 100 mM.

In some embodiments, C5 inhibitor (e.g., R5000 and/or an activemetabolite or variant thereof) compositions may include from about 0.01mg/mL to about 4000 mg/mL of a C5 inhibitor. In some cases, C5inhibitors are present at a concentration of from about 1 mg/mL to about400 mg/mL.

Isotopic Variations

Polypeptides of the present invention may comprise one or more atomsthat are isotopes. As used herein, the term “isotope” refers to achemical element that has one or more additional neutrons. In oneembodiment, polypeptides of the present invention may be deuterated. Asused herein, the term “deuterated” refers to a substance that has hadone or more hydrogen atoms replaced by deuterium isotopes. Deuteriumisotopes are isotopes of hydrogen. The nucleus of hydrogen contains oneproton while deuterium nuclei contain both a proton and a neutron.Compounds and pharmaceutical compositions of the present invention maybe deuterated in order to change a physical property, such as stability,or to allow them to be used in diagnostic and experimental applications.

II. Methods of Use

Provided herein are methods of modulating complement activity usingcompounds and/or compositions of the invention.

Therapeutic Indications

An important component of all immune activity (innate and adaptive) isthe ability of the immune system to distinguish between self andnon-self cells. Pathology arises when the immune system is unable tomake this distinction. In the case of the complement system, vertebratecells express inhibitory proteins that protect them from the effects ofthe complement cascade and this ensures that the complement system isdirected against microbial pathogens. Many complement-related disordersand diseases are associated with abnormal destruction of self-cells bythe complement cascade.

Methods of the invention include methods of treating complement-relateddisorders with compounds and compositions of the invention. A“complement-related disorder,” as referred to herein, may include anycondition related to dysfunction of the complement system. e.g.,cleavage or processing of a complement component such as C5.

In some embodiments, methods of the invention include methods ofinhibiting complement activity in a subject. In some cases, thepercentage of complement activity inhibited in a subject may be at least10%, at least 20%, at least 30%, at least 40%, at least 50%, at least60%, at least 70%, at least 80%, at least, 85%, at least 90%, at least95%, at least 96%, at least 97%, at least 98° %, at least 99%, at least99.5%, or at least 99.9%. In some cases, this level of inhibition and/ormaximum inhibition of complement activity may be achieved by from about1 hour after an administration to about 3 hours after an administration,from about 2 hours after an administration to about 4 hours after anadministration, from about 3 hours after an administration to about 10hours after an administration, from about 5 hours after anadministration to about 20 hour after an administration, or from about12 hours after an administration to about 24 hours after anadministration. Inhibition of complement activity may continuethroughout a period of at least 1 day, of at least 2 days, of at least 3days, of at least 4 days, of at least 5 days, of at least 6 days, of atleast 7 days, of at least 2 weeks, of at least 3 weeks, or at least 4weeks. In some cases, this level of inhibition may be achieved throughdaily administration. Such daily administration may includeadministration for at least 2 days, for at least 3 days, for at least 4days, for at least 5 days, for at least 6 days, for at least 7 days, forat least 2 weeks, for at least 3 weeks, for at least 4 weeks, for atleast 2 months, for at least 4 months, for at least 6 months, for atleast 1 year, or for at least 5 years. In some cases, subjects may beadministered compounds or compositions of the present disclosure for thelife of such subjects.

In some embodiments, methods of the invention include methods ofinhibiting C5 activity in a subject. “C5-dependent complement activity”or “C5 activity,” as used herein refers to activation of the complementcascade through cleavage of C5, the assembly of downstream cleavageproducts of C5, or any other process or event attendant to, or resultingfrom, the cleavage of C5. In some cases, the percentage of C5 activityinhibited in a subject may be at least 10%, at least 20%, at least 30%,at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, atleast, 85%, at least 90%, at least 95%, at least 96%, at least 97%, atleast 98%, at least 99%, at least 99.5%, or at least 99.9%.

In some embodiments, methods of the invention may include methods ofinhibiting hemolysis by administering one or more compounds orcompositions of the invention to a subject or patient in need thereof.According to some such methods, hemolysis may be reduced by from about25% to about 99%. In other embodiments, hemolysis is reduced by fromabout 10% to about 40%, from about 25% to about 75%, from about 30% toabout 60%, from about 50% to about 90%, from about 75% to about 95%,from about 90% to about 99%, or from about 97% to about 99.5%. In somecases, hemolysis is reduced by at least 50%, 60%, 70%, 80%, 90% or 95%.

According to some methods, the percent inhibition of hemolysis is fromabout ≥90% to about ≥99% (e.g., ≥91%, ≥92%, ≥93%, ≥94%, ≥95%, ≥96%,≥97%, ≥98%). In some cases, this level of inhibition and/or maximuminhibition of hemolysis may be achieved by from about 1 hour after anadministration to about 3 hours after an administration, from about 2hours after an administration to about 4 hours after an administration,from about 3 hours after an administration to about 10 hours after anadministration, from about 5 hours after an administration to about 20hour after an administration or from about 12 hours after anadministration to about 24 hours after an administration. Inhibition ofhemolysis activity levels may continue throughout a period of at least 1day, of at least 2 days, of at least 3 days, of at least 4 days, of atleast 5 days, of at least 6 days, of at least 7 days, of at least 2weeks, of at least 3 weeks, or at least 4 weeks. In some cases, thislevel of inhibition may be achieved through daily administration. Suchdaily administration may include administration for at least 2 days, forat least 3 days, for at least 4 days, for at least 5 days, for at least6 days, for at least 7 days, for at least 2 weeks, for at least 3 weeks,for at least 4 weeks, for at least 2 months, for at least 4 months, forat least 6 months, for at least 1 year, or for at least 5 years. In somecases, subjects may be administered compounds or compositions of thepresent disclosure for the life of such subjects.

C5 inhibitors of the invention may be used to treat one or moreindications, wherein few or no adverse effects occur as a result of theC5 inhibitor treatment. In some cases, no adverse cardiovascular,respiratory, and/or central nervous system (CNS) effects occur. In somecases, no changes in heart rate and/or arterial blood pressure occur. Insome cases, no changes to respiratory rate, tidal volume, and/or minutevolume occur.

By “lower” or “reduce” in the context of a disease marker or symptom ismeant a significant decrease in such level, often statisticallysignificant. The decrease can be, for example, at least 10%, at least20%, at least 30%, at least 40% or more, and is preferably down to alevel accepted as within the range of normal for an individual withoutsuch disorder.

By “increase” or “raise” in the context of a disease marker or symptomis meant a significant rise in such level, often statisticallysignificant. The increase can be, for example, at least 10%, at least20%, at least 30%, at least 40% or more, and is preferably up to a levelaccepted as within the range of normal for an individual without suchdisorder.

A treatment or preventive effect is evident when there is a significantimprovement, often statistically significant, in one or more parametersof disease status, or by a failure to worsen or to develop symptomswhere they would otherwise be anticipated. As an example, a favorablechange of at least 10% in a measurable parameter of disease, andpreferably at least 20%, 30%, 40%, 50% or more can be indicative ofeffective treatment. Efficacy for a given compound or composition canalso be judged using an experimental animal model for the given diseaseas known in the art. When using an experimental animal model, efficacyof treatment is evidenced when a statistically significant modulation ina marker or symptom is observed.

Paroxysmal Nocturnal Hemoglobinuria

In some embodiments, provided herein are methods of treating paroxysmalnocturnal hemoglobinuria (PNH) with compounds or compositions, e.g.,pharmaceutical compositions, of the invention. PNH is a rarecomplement-related disorder caused by an acquired mutation in thephosphatidylinositol glycan anchor biosynthesis, class A (PIG-A) genethat originates from a multipotent hematopoietic stem cell (Pu, J. J. etal., Clin Transl Sci. 2011 June; 4(3):219-24). PNH is characterized bybone marrow disorder, hemolytic anemia and thrombosis. The PIG-A geneproduct is necessary for the production of a glycolipid anchor,glycosylphosphatidylinositol (GPI), utilized to tether proteins to theplasma membrane. Two complement-regulatory proteins responsible forprotecting cells from lytic activity of the terminal complement complex,CD55 (decay accelerating factor) and CD59 (membrane inhibitor ofreactive lysis), become nonfunctional in the absence of GPI. This leadsto C5 activation and accumulation of specific complement proteins on thesurface of red blood cells (RBCs) leading to complement-mediateddestruction of these cells.

Patient with PNH initially present with hemoglobinuria, abdominal pain,smooth muscle dystonias, and fatigue, e.g., PNH-related symptoms ordisorders. PNH is also characterized by intravascular hemolysis (theprimary clinical manifestation of the disease) and venous thrombosis.Venous thrombosis may occur in unusual sites, including, but not limitedto hepatic, mesenteric, cerebral, and dermal veins. (Parker, C. et al.,2005. Blood. 106: 3699-709 and Parker, C. J., 2007. Exp Hematol. 35:523-33). Currently, eculizumab (SOLIRIS®, Alexion Pharmaceuticals,Cheshire, Conn.), a C5 inhibitor monoclonal antibody, is the onlyapproved treatment for PNH.

Treatment with eculizumab results in an adequate control ofintravascular hemolysis in most PNH patients (Schrezenmeier, H. et al.,2014. Haematologica. 99: 922-9). However, Nishimura and colleagues havedescribed 11 patients in Japan (3.2% of patients with PNH) who havemutations in the C5 gene that prevent binding of eculizumab to C5 and donot respond to treatment with the antibody (Nishimura, J-I. et al.,2014. N Engl J Med. 370: 632-9). Further, eculizumab is administeredevery 2 weeks as an IV infusion under the supervision of a healthcareprofessional, which is inconvenient and poses a burden to patients.

Long-term IV administration has the potential to lead to seriouscomplications such as infections, local thrombosis, hematomas, andprogressively reduced venous access. Additionally, eculizumab is a largeprotein, and is associated with risk of immunogenicity andhypersensitivity. Finally, while eculizumab binds C5 and prevents C5bgeneration, any C5b generated through incomplete inhibition can initiateMAC formation and cause hemolysis.

The peripheral blood of patients with PNH can vary in the proportions ofnormal and abnormal cells. The disease is sub-classified according tothe International PNH Interest Group based on clinical features, bonemarrow characteristics, and the percentage of GPI-AP-deficientpolymorphonuclear leukocytes (PMNs). As GPI-AP-deficient red blood cellsare more sensitive to destruction in PNH patients, the flow cytometryanalysis of PMNs is considered more informative (Parker, C. J., 2012.Curr Opin Hematol. 19: 141-8). Flow cytometry analysis in classic PNHshows 50 to 100% GPI-AP-deficient PMNs.

The hemolytic anemia of PNH is independent of autoantibodies (Coombsnegative) and results from uncontrolled activation of the AlternativePathway (AP) of complement.

In some embodiments, compounds and composition, e.g., pharmaceuticalcompositions, of the present invention are particularly useful in thetreatment of PNH. Such compounds and compositions may include C5inhibitors (e.g., R5000 and/or an active metabolite or variant thereof).C5 inhibitors of the invention, useful for treatment of PNH may, in somecases, block the cleavage of C5 into C5a and C5b. In some cases, C5inhibitors of the invention may be used as an alternative to eculizumabtherapy for PNH. Unlike eculizumab, C5 inhibitors of the invention maybind C5b, preventing C6 binding and subsequent assembly of the C5b-9MAC.

In some cases, R5000 and/or active metabolites or variants thereof,alone or in compositions, may be used to treat PNH in subjects. Suchsubjects may include subjects that have had adverse effects with, beenunresponsive to, demonstrated reduced responsiveness with, ordemonstrated resistance to other treatments (e.g., with eculizumab). Insome embodiments, treatment with compounds and compositions of thepresent disclosure may inhibit hemolysis of PNH erythrocytes in a dosedependent manner.

In some embodiments, R5000 and/or an active metabolite or variantthereof is administered in combination with eculizumab in a regimenwhich may involve parallel or serial treatment.

Based on sequence and structural data. R5000 and/or active metabolitesor variants thereof may be particularly useful for the treatment of PNHin the limited number of patients with polymorphisms in the C5 gene thatprevent binding of eculizumab to C5. An example of such patients arethose with a single missense C5 heterozygous mutation, c.2654G→A, whichpredicts the polymorphism p.Arg885His (R885H; for a description of thisand other polymorphisms at position 885, see Nishimura, J. et al., NEngl J Med. 2014. 370(7):632-9, the contents of which are hereinincorporated by reference in their entirety). This mutation disrupts theability of eculizumab to bind to C5 in carriers of the mutation. R5000and R5001, however, are capable of binding C5 carrying the R885Hsubstitution. Accordingly, in some embodiments, methods of the presentdisclosure include inhibiting C5 activity and/or treating PNH insubjects carrying the polymorphism p.Arg885His.

Like eculizumab, R5000 and R5001 block the proteolytic cleavage of C5into C5a and C5b. Unlike eculizumab, R5000 and R5001 can also bind toC5b and block association with C6, preventing the subsequent assembly ofthe MAC. Therefore, advantageously any C5b that arises from incompleteinhibition by R5000 and/or R5001 is prevented from binding C6 andcompleting assembly of the MAC.

In some cases, R5000 and/or active metabolites or variants thereof maybe used as a therapeutic alternative to eculizumab for patients with PNHand may offer added efficacy without the inconvenience and liabilitiesof IV administration and known risks of immunogenicity andhypersensitivity associated with monoclonal antibodies. Further, theserious complications of long-term IV administration, such asinfections, loss of venous access, local thrombosis, and hematomas, maybe overcome by R5000 and/or R5001 given by subcutaneous (SC) injection.

In some embodiments, methods of the present disclosure include treatingPNH in subjects that have not been previously treated with eculizumab.Such methods may include administering C5 inhibitors to the subject. TheC5 inhibitors may include R5000 and/or metabolites or variants thereof.In some aspects, the C5 inhibitors are administered two or more times atregular intervals. The intervals may be from about every hour to aboutevery 12 hours, from about every 2 hours to about every 24 hours, fromabout every 4 hours to about every 36 hours, from about every 8 hours toabout every 48 hours, from about every 12 hours to about every 60 hours,from about every 18 hours to about every 72 hours, from about every 30hours to about every 84 hours, from about every 40 hours to about every96 hours, from about every 50 hours to about every 108 hours, from aboutevery 60 hours to about every 120 hours, from about every 70 hours toabout every 132 hours, from about every 80 hours to about every 168hours, from about every day to about every week, from about every weekto about every month, or longer than every month. C5 inhibitoradministration may include administering C5 inhibitors at an initialloading dose. The initial loading dose may be from about 0.01 mg/kg toabout 1 mg/kg, from about 0.05 mg/kg to about 2 mg/kg, from about 0.1mg/kg to about 3 mg/kg, from about 0.2 mg/kg to about 4 mg/kg, fromabout 0.3 mg/kg to about 5 mg/kg, from about 0.6 mg/kg to about 6 mg/kg,from about 1.5 mg/kg to about 10 mg/kg, or from about 5 mg/kg to about50 mg/kg. C5 inhibitor administration may include administering C5inhibitors at an initial treatment dose. The initial treatment dose mayinclude administering C5 inhibitors two or more times at regularintervals after the initial loading dose. The initial treatment dose maybe from about 0.01 mg/kg to about 1 mg/kg, from about 0.05 mg/kg toabout 2 mg/kg, from about 0.1 mg/kg to about 3 mg/kg, from about 0.2mg/kg to about 4 mg/kg, from about 0.3 mg/kg to about 5 mg/kg, fromabout 0.6 mg/kg to about 6 mg/kg, from about 1.5 mg/kg to about 10mg/kg, or from about 5 mg/kg to about 50 mg/kg. Initial treatment dosesmay be substituted with modified treatment doses after a period ofadministration with the initial treatment dose. The period may be fromabout 1 day to about 10 days, from about 1 week to about 3 weeks, fromabout 2 weeks to about 4 weeks, or more than 4 weeks. The modifiedtreatment dose may be from about 0.01 mg/kg to about 1 mg/kg, from about0.05 mg/kg to about 2 mg/kg, from about 0.1 mg/kg to about 3 mg/kg, fromabout 0.2 mg/kg to about 4 mg/kg, from about 0.3 mg/kg to about 5 mg/kg,from about 0.6 mg/kg to about 6 mg/kg, from about 1.5 mg/kg to about 10mg/kg, or from about 5 mg/kg to about 50 mg/kg. The modified treatmentdose may include an increase in C5 inhibitor levels administered.Lactate dehydrogenase (LDH) levels in the subject may be monitored overthe course of treatment. Initial treatment doses may be substituted withmodified treatment doses based on changes in LDH levels observed. Insome aspects, subjects are transitioned to a modified treatment doseafter LDH levels equal to or less than 1.5 times the upper limit normalare detected. In some embodiments, hemolysis in subject serum isreduced. In some embodiments, no adverse events (e.g., injectionreactions or systemic infections) are observed in response to treatment.C5 inhibitor administration may include self-administration (e.g., usingan auto-injector device). The self-administration may be monitored, forexample, by a medical professional. In some aspects, theself-administration may be remotely monitored. Monitoring may be carriedout using a smart device.

It has been reported that eculizumab does not completely abolish C5activity in vitro under conditions that mimic strong activation,potentially leaving patients vulnerable to inadequate disease control(see Brodsky et al., 2017. Blood 129; 922-923 and Harder et al., 2017.Blood. 129:970-980). This is referred to as residual C5 activity.Residual C5 activity may be due to inability of eculizumab to prevent C5association with the alternative pathway C5-convertase (comprising twosubunits of C3b as well as one Bb component). In some embodiments, R5000and/or active metabolites or variants thereof may be used to inhibitassociation between C5 and alternative pathway C5-convertase.

Residual C5 activity may also exist where strong complement activationresults in C5 cleavage before eculizumab can bind. Like eculizumab.R5000 and active metabolites or variants thereof bind to C5 and inhibitcleavage of C5 and activation of the terminal complement cascade. R5000and R5001, however, bind C5 at a different site than eculizumab andtherefore have a distinct molecular mechanism of inhibition. Further,R5000 and R5001 may associate with C5b after cleavage to preventsubsequent hemolysis. In some embodiments, R5000 and/or activemetabolites or variants thereof may be used to improve complementinhibition under conditions where some hemolytic activity persistsduring or after treatment with eculizumab. Accordingly, in someembodiments, the present disclosure provides methods of inhibitingresidual C5 activity by contacting C5 with R5000 and/or an activemetabolite thereof. The C5 may be C5 of a subject with PNH. The C5 maybe C5 of a subject with a C5 polymorphism (e.g., pArg885His). In someembodiments, methods of the present disclosure include treating subjectswith PNH, wherein residual C5 activity remains after prior or currenttreatment with eculizumab, by administering R5000 and/or activemetabolites or variants thereof.

Inflammatory Indications

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to treat subjects withdiseases, disorders and/or conditions related to inflammation.Inflammation may be upregulated during the proteolytic cascade of thecomplement system. Although inflammation may have beneficial effects,excess inflammation may lead to a variety of pathologies (Markiewski etal. 2007. Am J Pathol. 17: 715-27). Accordingly, compounds andcompositions of the present invention may be used to reduce or eliminateinflammation associated with complement activation.

Sterile Inflammation

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the present invention may be used to treat, prevent ordelay development of sterile inflammation. Sterile inflammation isinflammation that occurs in response to stimuli other than infection.Sterile inflammation may be a common response to stress such as genomicstress, hypoxic stress, nutrient stress or endoplasmic reticulum stresscaused by a physical, chemical, or metabolic noxious stimuli. Sterileinflammation may contribute to pathogenesis of many diseases such as,but not limited to, ischemia-induced injuries, rheumatoid arthritis,acute lung injuries, drug-induced liver injuries, inflammatory boweldiseases and/or other diseases, disorders or conditions. Mechanism ofsterile inflammation and methods and compositions for treatment,prevention and/or delaying of symptoms of sterile inflammation mayinclude any of those taught by Rubartelli et al. in Frontiers inImmunology, 2013, 4:398-99, Rock et al. in Annu Rev Immunol. 2010,28:321-342 or in U.S. Pat. No. 8,101,586, the contents of each of whichare herein incorporated by reference in their entirety.

Systemic Inflammatory Response (SIRS) and Sepsis

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to treat and/or preventsystemic inflammatory response syndrome (SIRS). SIRS is inflammationaffecting the whole body. Where SIRS is caused by an infection, it isreferred to as sepsis. SIRS may also be caused by non-infectious eventssuch as trauma, injury, burns, ischemia, hemorrhage and/or otherconditions. Among negative outcomes associated with SIRS and/or sepsisis multi-organ failure (MOF). Complement inhibition at the C3 level inGram-negative sepsis significantly protects the organs against E.coli-induced progressive MOF, but also hinders bacterial clearance.Compounds and compositions described herein include C5 complementcomponent inhibitors that may be administered to subjects with sepsis toprovide the benefits of organ protection without detrimentally alteringbacterial clearance.

In some embodiments, the present disclosure provides methods of treatingsepsis. Sepsis may be induced by microbial infection. The microbialinfection may include at least one Gram-negative infectious agent. Asused herein, the term “infectious agent” refers to any entity thatinvades or otherwise infects a cell, tissue, organ, compartment, orfluid of a sample or subject. In some cases, infectious agents may bebacteria, viruses, or other pathogens. Gram negative infectious agentsare Gram-negative bacteria. Gram-negative infectious agents may include,but are not limited to E. coli.

Methods of treating sepsis may include the administration of one or moreC5 inhibitors to a subject. The C5 inhibitor may be R5000. According tosome methods, complement activation may be reduced or prevented.Reduction or prevention of complement activity may be determined bydetecting one or more products of complement activity in a subjectsample. Such products may include C5 cleavage products (e.g., C5a andC5b) or downstream complexes formed as a result of C5 cleavage (e.g.,C5b-9). In some embodiments, the present disclosure provides methods oftreating sepsis with R5000, wherein levels of C5a and/or C5b-9 arereduced or eliminated in the subject and/or in at least one sampleobtained from the subject. For example, C5a and/or C5b-9 levels may bereduced in subjects administered R5000 (or in samples obtained from suchsubjects) by from about 0% to about 0.05%, from about 0.01% to about 1%,from about 0.05% to about 2%, from about 0.1% to about 5%, from about0.5% to about 10%, from about 1% to about 15%, from about 5% to about25%, from about 10% to about 50%, from about 20% to about 60%, fromabout 25% to about 75%, from about 50% to about 100% when compared tosubjects (or subject samples) not treated with R5000 (including subjectstreated with other complement inhibitors) or when compared to the samesubject (or subject samples) during a pre-treatment period or an earlierperiod of treatment.

In some embodiments, C5b-9 levels reduced by R5000 treatment are C5b-9levels associated with one or more of the classical pathway ofcomplement activation, the alternative pathway of complement activation,and the lectin pathway of complement activation.

In some embodiments, the presence, absence, and/or levels of one or morefactors associated with sepsis may be modulated by administering R5000to a subject with sepsis. The presence or absence of such factors may bedetermined using assays for their detection. Changes in factor levelsmay be determined by determining the level of such factors in a subjectwith sepsis after R5000 treatment and comparing those levels to earlierlevels in the same subject (either before R5000 treatment or during oneor more earlier periods of treatment) or to levels in subjects that arenot treated with R5000 (including subjects with sepsis that receive notreatment or subjects that receive some other form of treatment).Comparisons may be presented by percentage differences in factor levelsbetween R5000 treated subjects and subjects not treated with R5000.

C5 cleavage product may include any proteins or complexes that mayresult from C5 cleavage. In some cases, C5 cleavage products mayinclude, but are not limited to, C5a and C5b. C5b cleavage product maygo on to form a complex with complement proteins C6, C7, C8, and C9(referred to herein as “C5b-9”). Accordingly, C5 cleavage products thatinclude C5b-9 may be detected and/or quantitated to determine whethercomplement activity has been reduced or prevented. Detection of C5b-9deposition may be carried out, for example, through the use of theWIESLAB® ELISA (Euro Diagnostica, Malmo, Sweden) kit. Quantitation ofcleavage products may be measured in “complement arbitrary units” (CAU)as described by others (e.g., see Bergseth G et al., 2013. Mol Immunol.56:232-9, the contents of which are herein incorporated by reference intheir entirety).

In some embodiments, treating sepsis with a C5 inhibitor (e.g., R5000)may reduce or prevent C5b-9 production.

According to the present invention, administration of R5000 to a subjectmay result in modulation of bacterial clearance in the subject and/or inat least one sample obtained from the subject. Bacterial clearance, asreferred to herein, is the partial or complete removal/reduction ofbacteria from a subject or sample. Clearance may occur by way of killingor otherwise rendering bacteria incapable of growth and/or reproduction.In some cases, bacterial clearance may occur through bacterial lysisand/or immune destruction (e.g., through phagocytosis, bacterial celllysis, opsonization, etc.). According to some methods, bacterialclearance in subjects treated with C5 inhibitors (e.g., R5000) may haveno effect or a beneficial effect on bacterial clearance. This may occurdue to the absence of or a decreased effect on C3b levels with C5inhibition. In some embodiments, methods of treating sepsis with R5000may avoid interference with C3b-dependent opsonization or enhanceC3b-dependent opsonization.

In some cases, bacterial clearance with R5000 treatment may be enhancedin comparison to bacterial clearance in an untreated subject or in asubject treated with another form of complement inhibitor, for example,a C3 inhibitor. In some embodiments, subjects with sepsis that aretreated with R5000 may experience 0% to at least 100% enhanced bacterialclearance when compared to bacterial clearance in subjects not treatedwith R5000 (including subjects treated with other complement inhibitors)or when compared to earlier bacterial clearance levels in the samesubject before treatment with R5000 or during an earlier treatmentperiod with R5000. For example, bacterial clearance in subjects treatedwith R5000 and/or in at least one sample obtained from such subjects maybe enhanced by from about 0% to about 0.05%, from about 0.01% to about1%, from about 0.05% to about 2%, from about 0.1% to about 5%, fromabout 0.5% to about 10%, from about 1% to about 15%, from about 5% toabout 25%, from about 10%0 to about 50%, from about 20% to about 60%,from about 25% to about 75%, from about 50% to about 100% when comparedto subjects not treated with R5000 (including subjects treated withother complement inhibitors) and/or when compared to samples obtainedfrom such subjects or when compared to the same subject during apre-treatment period or an earlier period of treatment and/or whencompared to samples obtained from the same subject during apre-treatment period or an earlier period of treatment.

Bacterial clearance may be measured in a subject by directly measuringbacterial levels in the subject and/or a subject sample or by measuringone or more indicators of bacterial clearance (e.g., levels of bacterialcomponents released after bacterial lysis). Bacterial clearance levelsmay then be determined by comparison to a previous measurement ofbacterial/indicator levels or to bacterial/indicator levels in a subjectreceiving no treatment or a different treatment. In some cases, colonyforming units (cfu) from collected blood (e.g., to generate cfu/ml ofblood) are examined to determine bacterial levels.

In some embodiments, sepsis treatment with R5000 may be carried out withno effect on phagocytosis or without substantial impairment ofphagocytosis. This may include neutrophil-dependent and/ormonocyte-dependent phagocytosis. Unimpaired or substantially unimpairedphagocytosis with R5000 treatment may be due to limited or non-existentchanges to C3b levels with R5000 treatment.

Oxidative burst is a C5a-dependent process, characterized by theproduction of peroxide by certain cells, particularly macrophages andneutrophils, following challenge by a pathogen (see Mollnes T. E. etal., 2002. Blood 100, 1869-1877, the contents of which are hereinincorporated by reference in their entirety).

In some embodiments, oxidative burst may be reduced or prevented insubjects with sepsis after treatment with R5000. This may be due to adecrease in C5a levels with R5000-dependent C5 inhibition. Oxidativeburst may be reduced in subjects administered R5000 by from about 0% toabout 0.05%, from about 0.01% to about 1%, from about 0.05% to about 2%,from about 0.1% to about 5%, from about 0.5% to about 10%, from about 1%to about 15%, from about 5% to about 25%, from about 10% to about 50%,from about 20% to about 60%, from about 25% to about 75%, from about 50%to about 100% when compared to subjects not treated with R5000(including subjects treated with other complement inhibitors) or whencompared to the same subject during a pre-treatment period or an earlierperiod of treatment.

Lipopolysaccharide (LPS) is a component of bacterial cell coats that isa known immune stimulator. Complement-dependent bacteriolysis can leadto release of LPS, contributing to inflammatory responses, such as thosecharacteristic of sepsis. In some embodiments, treatment of sepsis withR5000 may reduce LPS levels. This may be due to a decrease incomplement-mediated bacteriolysis with inhibition of C5-dependentcomplement activity. In some embodiments, LPS levels may be reduced oreliminated in subjects administered R5000 (or in samples obtained fromsuch subjects) by from about 0% to about 0.05%, from about 0.01% toabout 1%, from about 0.05% to about 2%, from about 0.1% to about 5%,from about 0.5% to about 10%, from about 1% to about 15%, from about 5%to about 25%, from about 10% to about 50%/o, from about 20% to about60%, from about 25% to about 75%, from about 50% to about 100% whencompared to subjects (or subject samples) not treated with R5000(including subjects treated with other complement inhibitors) or whencompared to the same subject (or subject samples) during a pre-treatmentperiod or an earlier period of treatment.

In some embodiments, LPS levels may be reduced by 100% in subjects (orsubject samples) with sepsis that are treated with R5000 as compared tosubjects (or subject samples) with sepsis that are not treated withR5000 (including subjects receiving one or more other forms oftreatment) or when compared to the same subject (or subject sample)during a pre-treatment period or an earlier period of treatment.

In some embodiments of the present disclosure, sepsis-induced levels ofone or more cytokine may be reduced with R5000 treatment. Cytokinesinclude a number of cell signaling molecules that stimulate immuneresponses to infection. “Cytokine storm” is a dramatic upregulation ofat least four cytokines, interleukin (IL)-6, IL-8, monocytechemoattractant protein-1 (MCP-1), and tumor necrosis factor alpha(TNFα), that may result from bacterial infection and contribute tosepsis. C5a is known to induce the synthesis and activity of thesecytokines. Inhibitors of C5, may therefore reduce cytokine levels byreducing levels of C5a. Cytokine levels may be evaluated in subjects orsubject samples to evaluate the ability of C5 inhibitors to reduce thelevels of one or more inflammatory cytokines upregulated during sepsis.IL-6, IL-8, MCP-1 and/or TNFα levels may be decreased in subjectsadministered R5000 by from about 0% to about 0.05%, from about 0.01% toabout 1%, from about 0.05% to about 2%, from about 0.1% to about 5%,from about 0.5% to about 10%, from about 1% to about 15%, from about 5%to about 25%, from about 10% to about 50%, from about 20% to about 60%,from about 25% to about 75%, from about 50% to about 100% when comparedto subjects not treated with R5000 (including subjects treated withother complement inhibitors) or when compared to the same subject duringa pre-treatment period or an earlier period of treatment. In someembodiments, IL-6, IL-8, MCP-1, and/or TNFα levels may be reduced by100% in subjects with sepsis that are treated with R5000 as compared tosubjects with sepsis that are not treated with R5000 (including subjectsreceiving one or more other forms of treatment) or when compared to thesame subject during a pre-treatment period or an earlier period oftreatment.

One complication associated with sepsis is dysregulation of coagulationand/or fibrinolysis pathways (Levi M., et al., 2013. Seminars inthrombosis and hemostasis 39, 559-66; Rittirsch D., et al., 2008. NatureReviews Immunology 8, 776-87; and Dempfle C., 2004. A Thromb Haemost.91(2):213-24, the contents of each of which are herein incorporated byreference in their entirety). While controlled local activation of thesepathways is important for defending against pathogens, systemic,uncontrolled activation may be harmful. Complement activity associatedwith bacterial infection may promote coagulation and/or fibrinolysisdysregulation due to increased host cell and tissue damage associatedwith MAC formation. In some embodiments, treatment of sepsis with R5000may normalize coagulation and/or fibrinolysis pathways.

Dysregulation of coagulation and/or fibrinolysis associated with sepsismay include disseminated intravascular coagulation (DIC). DIC is acondition that results in tissue and organ damage due to activation ofcoagulation and blood clot formation in small blood vessels. Thisactivity reduces blood flow to tissues and organs and consumes bloodfactors necessary for coagulation in the rest of the body. The absenceof these blood factors in the blood stream may lead to uncontrolledbleeding in other parts of the body. In some embodiments, treatment ofsepsis with R5000 may reduce or eliminate DIC.

Coagulation dysfunction associated with sepsis may be detected bymeasuring the activated partial thromboplastin time (APTT) and/orprothrombin time (PT). These are tests performed on plasma samples todetermine whether coagulation factor levels are low. In subjects withDIC, APTT and/or PT are prolonged due to reduced levels of coagulationfactors. In some embodiments, subject treatment of sepsis with R5000 maylower and/or normalize APTT and/or PT in samples obtained from treatedsubjects.

Coagulation dysfunction associated with sepsis may further be evaluatedthrough analysis of thrombin-antithrombin (TAT) complex levels and/orleukocyte expression of Tissue Factor (TF) mRNA. Increased levels of TATcomplex and leukocyte expression of TF mRNA are associated withcoagulation dysfunction and are consistent with DIC. In someembodiments, treatment of sepsis with R5000 may result in a reduction inTAT levels and/or leukocyte TF mRNA levels of from about 0.005% to about0.05%, from about 0.01% to about 1%, from about 0.05% to about 2%6, fromabout 0.1% to about 5%, from about 0.5% to about 10%, from about 1% toabout 15%, from about 5% to about 25%, from about 10% to about 50%, fromabout 20% to about 60%, from about 25% to about 75%, from about 50% toabout 100% when compared to subjects not treated with R5000 (includingsubjects treated with other complement inhibitors) or when compared tothe same subject during a pre-treatment period or an earlier period oftreatment. In some embodiments, TAT levels and/or leukocyte TF mRNAlevels may be reduced by 100% in subjects with sepsis that are treatedwith R5000 as compared to subjects with sepsis that are not treated withR5000 (including subjects receiving one or more other forms oftreatment) or when compared to the same subject during a pre-treatmentperiod or an earlier period of treatment.

Factor XII is a factor important for normal coagulation in plasma.Factor XII levels may be decreased in plasma samples taken from subjectswith coagulation dysfunction (e.g., DIC) due to consumption of FactorXII associated with coagulation in small blood vessels. In someembodiments, sepsis treatment with R5000 may reduce Factor XIIconsumption. Accordingly, Factor XII levels may be increased in plasmasamples taken from subjects with sepsis after R5000 treatment. FactorXII levels may be increased in plasma samples by from about 0.005% toabout 0.05%, from about 0.01% to about 1%, from about 0.05% to about 2%,from about 0.1% to about 5%, from about 0.5% to about 10%, from about 1%to about 15%, from about 5% to about 25%, from about 10% to about 50%,from about 20% to about 60%, from about 25% to about 75%, from about 50%to about 100% when compared to subjects not treated with R5000(including subjects treated with other complement inhibitors) or whencompared to plasma samples taken from the same subject during apre-treatment period or an earlier period of treatment. In someembodiments, Factor XII levels may be increased by 100% in plasmasamples from subjects with sepsis that are treated with R5000 ascompared to plasma samples from subjects with sepsis that are nottreated with R5000 (including subjects receiving one or more other formsof treatment) or when compared to plasma samples taken from the samesubject during a pre-treatment period or an earlier period of treatment.

Fibrinolysis is the breakdown of fibrin due to enzymatic activity, aprocess critical for clot formation. Fibrinolysis dysregulation mayoccur in severe sepsis and is reported to affect normal clotting inbaboons challenged with E. coli (P. de Boer J. P., et al., 1993.Circulatory shock. 39, 59-67, the contents of which are hereinincorporated by reference in their entirety). Plasma indicators ofsepsis-dependent fibrinolysis dysfunction (including, but not limited tofibrinolysis dysfunction associated with DIC) may include, but are notlimited to decreased fibrinogen levels (indicating a reduced ability toform fibrin clots), increased tissue plasminogen activator (tPA) levels,increased plasminogen activator inhibitor type 1 (PAI-1) levels,increased plasmin-antiplasmin (PAP) levels, increased fibrinogen/fibrindegradation products, and increased D-dimer levels. In some embodiments,treatment of sepsis with R5000 may result in a decrease in plasmafibrinogen levels and/or an increase in plasma levels of tPA, PAI-1,PAP, fibrinogen/fibrin degradation product, and/or D-dimer of from about0.005% to about 0.05%, from about 0.01% to about 1%, from about 0.05% toabout 2%, from about 0.1% to about 5%, from about 0.5% to about 10%,from about 1% to about 15%, from about 5% to about 25%, from about 10%to about 50%, from about 20% to about 60%, from about 25% to about 75%,from about 50% to about 100% when compared to levels in plasma samplesfrom subjects not treated with R5000 (including subjects treated withother complement inhibitors) or when compared to levels in plasmasamples taken from the same subject during a pre-treatment period or anearlier period of treatment. In some embodiments, sepsis-associateddecrease in plasma fibrinogen levels and/or a sepsis-associated increasein plasma levels of tPA, PAI-1, PAP, fibrinogen/fibrin degradationproduct, and/or D-dimer may differ by at least 10,000% when compared tolevels in plasma samples from subjects with sepsis that are treated withR5000.

Another consequence of overactive complement activity associated withsepsis is a reduction in red blood cells due to complement-dependenthemolysis and/or C3b-dependent opsonization. Methods of treating sepsiswith R5000 according to the present disclosure may include reducingcomplement-dependent hemolysis. One method of evaluatingcomplement-dependent hemolysis associated with sepsis involves obtaininga complete blood cell count. Complete blood cell counts may be obtainedthrough automated processes that count the cell types present in bloodsamples. Results from complete blood cell count analysis typicallyinclude levels of hematocrit, red blood cell (RBC) counts, white bloodcell (WBC) counts, and platelets. Hematocrit levels are used todetermine the percentage of blood (by volume) that is made up of redblood cells. Hematocrit levels, platelet levels, RBC levels, and WBClevels may be reduced in sepsis due to hemolysis. In some embodiments,treatment of sepsis with R5000 increases hematocrit levels, plateletlevels, RBC levels, and/or WBC levels. Increases may be immediate or mayoccur over time with treatment (e.g., single or multiple dosetreatments).

In some embodiments, subject treatment with R5000 may decrease leukocyte(e.g., neutrophils and macrophages) activation associated with sepsis.“Activation.” as used herein in the context of leukocytes refers tomobilization and/or maturation of these cells to carryout associatedimmune functions. Decreased leukocyte activation with R5000 treatmentmay be determined by assessing the subject treated or a sample obtainedfrom the subject treated.

In some embodiments, treatment of sepsis with R5000 may improve one ormore vital signs in subjects being treated. Such vital signs mayinclude, but are not limited to, heart rate, mean systemic arterialpressure (MSAP), respiration rate, oxygen saturation, and bodytemperature.

In some embodiments, treatment of sepsis with R5000 may stabilize orreduce capillary leak and/or endothelial barrier dysfunction associatedwith sepsis (i.e., to maintain or improve capillary leak and/orendothelial barrier dysfunction). Stabilization or reduction ofcapillary leak and/or endothelial barrier dysfunction may be determinedby measuring total plasma protein levels and/or plasma albumin levels.An increase in either level in comparison to plasma levels associatedwith sepsis may indicate reduced capillary leak. Accordingly, treatmentof sepsis with R5000 may increase levels of total plasma protein and/orplasma albumin.

Methods of the present disclosure may include methods of treating sepsiswith R5000, wherein levels of one or more acute phase proteins arereduced. Acute phase proteins are proteins produced by the liver underinflammatory condition. R5000 treatment may reduce inflammationassociated with sepsis and lead to decreased production of acute phaseproteins by the liver.

According to some methods of the invention, sepsis-induced organ damageand/or organ dysfunction may be reduced, reversed, or prevented bytreatment with R5000. Indicators that may be reduced with improved organfunction may include, but are not limited to plasma lactate(demonstrating improved vascular perfusion and clearance), creatinine,blood urea nitrogen (both indicating improved kidney function), andliver transaminases (indicating improved liver function). In someembodiments, febrile response, risk of secondary infection and/or riskof sepsis reoccurrence is reduced in subjects treated for sepsis withR5000.

Methods of the present disclosure may include preventing sepsis-relateddeath and/or improving survival time of subjects afflicted with sepsisthrough treatment with R5000. Improved survival time may be determinedthrough comparison of survival time in R5000-treated subjects tosurvival time in un-treated subjects (including subjects treated withone or more other forms of treatment). In some embodiments, survivaltimes are increased by at least 1 day, at least 2 days, at least 3 days,at least 4 days, at least 5 days, at least 6 days, at least 7 days, atleast 2 weeks, at least 1 month, at least 2 months, at least 4 months,at least 6 months, at least 1 year, at least 2 years, at least 5 years,or at least 10 years.

In some embodiments, administration of R5000 is carried out in a singledose. In some embodiments, administration of R5000 is carried out inmultiple doses. For example, R5000 administration may includeadministration of an initial dose, followed by one or more repeat doses.Repeat doses may be administered from about 1 hour to about 24 hours,from about 2 hours to about 48 hours, from about 4 hours to about 72hours, from about 8 hours to about 96 hours, from about 12 hours toabout 36 hours, or from about 18 hours to about 60 hours after aprevious dose. In some cases, repeat doses may be administered 1 day, 2days, 3 days, 4 days, 5 days, 6 days, 7 days, 2 weeks, 4 weeks, 2months, 4 months, 6 months, or more than 6 months after a previous dose.In some cases, repeat doses may be administered as needed to stabilizeor reduce sepsis or to stabilize or reduce one or more effectsassociated with sepsis in a subject. Repeat doses may include the sameamount of R5000 or may include a different amount.

Compounds and compositions of the invention may be used to controland/or balance complement activation for prevention and treatment ofSIRS, sepsis and/or MOF. The methods of applying complement inhibitorsto treat SIRS and sepsis may include those in U.S. publication No.US2013/0053302 or in U.S. Pat. No. 8,329,169, the contents of each ofwhich are herein incorporated by reference in their entirety.

Acute Respiratory Distress Syndrome (ARDS)

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to treat and/or preventdevelopment of acute respiratory distress syndrome (ARDS). ARDS is awidespread inflammation of the lungs and may be caused by trauma,infection (e.g., sepsis), severe pneumonia and/or inhalation of harmfulsubstances. ARDS is typically a severe, life-threatening complication.Studies suggest that neutrophils may contribute to development of ARDSby affecting the accumulation of polymorphonuclear cells in the injuredpulmonary alveoli and interstitial tissue of the lungs. Accordingly,compounds and compositions of the invention may be administered toreduce and/or prevent tissue factor production in alveolar neutrophils.Compounds and compositions of the invention may further be used fortreatment, prevention and/or delaying of ARDS, in some cases accordingto any of the methods taught in International publication No.WO2009/014633, the contents of which are herein incorporated byreference in their entirety.

Periodontitis

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to treat or preventdevelopment of periodontitis and/or associated conditions. Periodontitisis a widespread, chronic inflammation leading to the destruction ofperiodontal tissue which is the tissue supporting and surrounding theteeth. The condition also involves alveolar bone loss (bone that holdsthe teeth). Periodontitis may be caused by a lack of oral hygieneleading to accumulation of bacteria at the gum line, also known asdental plaque. Certain health conditions such as diabetes ormalnutrition and/or habits such as smoking may increase the risk ofperiodontitis. Periodontitis may increase the risk of stroke, myocardialinfarction, atherosclerosis, diabetes, osteoporosis, pre-term labor, aswell as other health issues. Studies demonstrate a correlation betweenperiodontitis and local complement activity. Periodontal bacteria mayeither inhibit or activate certain components of the complement cascade.Accordingly, compounds and compositions of the invention may be used toprevent and/or treat periodontitis and associated diseases andconditions. Complement activation inhibitors and treatment methods mayinclude any of those taught by Hajishengallis in Biochem Pharmacol.2010, 15; 80(12): 1 and Lambris or in US publication No. US2013/0344082,the contents of each of which are herein incorporated by reference intheir entirety.

Dermatomyositis

In some embodiments, compounds, compositions, e.g., pharmaceuticalcompositions, and/or methods of the invention may be used to treatdermatomyositis. Dermatomyositis is an inflammatory myopathycharacterized by muscle weakness and chronic muscle inflammation.Dermatomyositis often begins with a skin rash that is associatedconcurrently or precedes muscle weakness. Compounds, compositions,and/or methods of the invention may be used to reduce or preventdermatomyositis.

Wounds and Injuries

Compounds and compositions, e.g., pharmaceutical compositions, of theinvention may be used to treat and/or promote healing of different typesof wounds and/or injuries. As used herein, the term “injury” typicallyrefers to physical trauma, but may include localized infection ordisease processes. Injuries may be characterized by harm, damage ordestruction caused by external events affecting body parts and/ororgans. Wounds are associated with cuts, blows, burns and/or otherimpacts to the skin, leaving the skin broken or damaged. Wounds andinjuries are often acute but if not healed properly they may lead tochronic complications and/or inflammation.

Wounds and Burn Wounds

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to treat and/or to promotehealing of wounds. Healthy skin provides a waterproof, protectivebarrier against pathogens and other environmental effectors. The skinalso controls body temperature and fluid evaporation. When skin iswounded these functions are disrupted making skin healing challenging.Wounding initiates a set of physiological processes related to theimmune system that repair and regenerate tissue. Complement activationis one of these processes. Complement activation studies have identifiedseveral complement components involved with wound healing as taught byvan de Goot et al. in J Burn Care Res 2009, 30:274-280 and Cazander etal. Clin Dev Immunol, 2012, 2012:534291, the contents of each of whichare herein incorporated by reference in their entirety. In some cases,complement activation may be excessive, causing cell death and enhancedinflammation (leading to impaired wound healing and chronic wounds). Insome cases, compounds and compositions of the present invention may beused to reduce or eliminate such complement activation to promote woundhealing. Treatment with compounds and compositions of the invention maybe carried out according to any of the methods for treating woundsdisclosed in International publication number WO2012/174055, thecontents of which are herein incorporated by reference in theirentirety.

Head Trauma

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to treat and/or promotehealing of head trauma. Head traumas include injuries to the scalp, theskull or the brain. Examples of head trauma include, but are not limitedto concussions, contusions, skull fracture, traumatic brain injuriesand/or other injuries. Head traumas may be minor or severe. In somecases, head trauma may lead to long term physical and/or mentalcomplications or death. Studies indicate that head traumas may induceimproper intracranial complement cascade activation, which may lead tolocal inflammatory responses contributing to secondary brain damage bydevelopment of brain edema and/or neuronal death (Stahel et al. in BrainResearch Reviews, 1998, 27: 243-56, the contents of which are hereinincorporated by reference in their entirety). Compounds and compositionsof the invention may be used to treat head trauma and/or to reduce orprevent related secondary complications. Methods of using compounds andcompositions of the invention to control complement cascade activationin head trauma may include any of those taught by Holers et al. in U.S.Pat. No. 8,911,733, the contents of which are herein incorporated byreference in their entirety.

Crush Injury

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to treat and/or promotehealing of crush injuries. Crush injuries are injuries caused by a forceor a pressure put on the body causing bleeding, bruising, fractures,nerve injuries, wounds and/or other damages to the body. Compounds andcompositions of the invention may be used to reduce complementactivation following crush injuries, thereby promoting healing aftercrush injuries (e.g. by promoting nerve regeneration, promoting fracturehealing, preventing or treating inflammation, and/or other relatedcomplications). Compounds and compositions of the invention may be usedto promote healing according to any of the methods taught in U.S. Pat.No. 8,703,136; International Publication Nos. WO2012/162215;WO2012/174055; or US publication No. US2006/0270590, the contents ofeach of which are herein incorporated by reference in their entirety.

Ischemia/Reperfusion Injury

In some embodiments, compounds, compositions, e.g., pharmaceuticalcompositions, and/or methods of the present disclosure may be used totreat injuries associated with ischemia and/or reperfusion. Suchinjuries may be associated with surgical intervention (e.g.,transplantation). Accordingly, compounds, compositions, and/or methodsof the present disclosure may be used to reduce or prevent ischemiaand/or reperfusion injuries.

Autoimmune Disease

The compounds and compositions, e.g., pharmaceutical compositions, ofthe invention may be used to treat subjects with autoimmune diseasesand/or disorders. The immune system may be divided into innate andadaptive systems, referring to nonspecific immediate defense mechanismsand more complex antigen-specific systems, respectively. The complementsystem is part of the innate immune system, recognizing and eliminatingpathogens. Additionally, complement proteins may modulate adaptiveimmunity, connecting innate and adaptive responses. Autoimmune diseasesand disorders are immune abnormalities causing the system to target selftissues and substances. Autoimmune disease may involve certain tissuesor organs of the body. Compounds and compositions of the invention maybe used to modulate complement in the treatment and/or prevention ofautoimmune diseases. In some cases, such compounds and compositions maybe used according to the methods presented in Ballanti et al. ImmunolRes (2013) 56:477-491, the contents of which are herein incorporated byreference in their entirety.

Anti-Phospholipid Syndrome (APS) and Catastrophic Anti-PhospholipidSyndrome (CAPS)

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatanti-phospholipid syndrome (APS) by complement activation control. APSis an autoimmune condition caused by anti-phospholipid antibodies thatcause the blood to clot. APS may lead to recurrent venous or arterialthrombosis in organs, and complications in placental circulationscausing pregnancy-related complications such as miscarriage, stillbirth, preeclampsia, premature birth and/or other complications.Catastrophic anti-phospholipid syndrome (CAPS) is an extreme and acuteversion of a similar condition leading to occlusion of veins in severalorgans simultaneously. Studies suggest that complement activation maycontribute to APS-related complications including pregnancy-relatedcomplications, thrombotic (clotting) complications, and vascularcomplications. Compound and compositions of the invention may be used totreat APS-related conditions by reducing or eliminating complementactivation. In some cases, compounds and compositions of the inventionmay be used to treat APS and/or APS-related complications according tothe methods taught by Salmon et al. Ann Rheum Dis 2002; 61(SupplII):ii46-ii50 and Mackworth-Young in Clin Exp Immunol 2004, 136:393-401,the contents of which are herein incorporated by reference in theirentirety.

Cold Agglutinin Disease

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to treat cold agglutinindisease (CAD), also referred to as cold agglutinin-mediated hemolysis.CAD is an autoimmune disease resulting from a high concentration of IgMantibodies interacting with red blood cells at low range bodytemperatures [Engelhardt et al. Blood, 2002, 100(5): 1922-23]. CAD maylead to conditions such as anemia, fatigue, dyspnea, hemoglobinuriaand/or acrocyanosis. CAD is related to robust complement activation andstudies have shown that CAD may be treated with complement inhibitortherapies. Accordingly, the present invention provides methods oftreating CAD using compounds and compositions of the invention. In somecases, compounds and compositions of the invention may be used to treatCAD according to the methods taught by Roth et al in Blood, 2009,113:3885-86 or in International publication No. WO2012/139081, thecontents of each of which are herein incorporated by reference in theirentirety.

Myasthenia Gravis

In some embodiments, compounds, compositions, e.g., pharmaceuticalcompositions, and/or methods of the invention may be used to treatMyasthenia gravis. Myasthenia gravis (MG) is a rare complement-mediatedautoimmune disease characterized by the production of autoantibodiestargeting proteins that are critical for the normal transmission ofelectrical signals from nerves to muscles. Although the prognosis of MGis generally benign, in 10% to 15% of patients disease control eithercannot be achieved with current therapies, or results in severe sideeffects of immunosuppressive therapy. This severe form of MG is known asrefractory MG (rMG), and affects approximately 9,000 individuals in theUnited States.

Patients present with muscle weakness that characteristically becomesmore severe with repeated use and recovers with rest. Muscle weaknesscan be localized to specific muscles, such as those responsible for eyemovements, but often progresses to more diffuse muscle weakness. rMG mayeven become life-threatening when muscle weakness involves the diaphragmand the other chest wall muscles responsible for breathing. This is themost feared complication of rMG, known as myasthenic crisis, andrequires hospitalization, intubation, and mechanical ventilation.Approximately 15% to 20% of patients experience a myasthenic crisiswithin two years of diagnosis.

The most common target of autoantibodies in MG is the acetylcholinereceptor, or AchR, located at the neuromuscular junction, the point atwhich a motor neuron transmits signals to a skeletal muscle fiber.Binding of anti-AchR autoantibodies to the muscle endplate results inactivation of the classical complement cascade and deposition of MAC onthe post-synaptic muscle fiber leading to local damage to the musclemembrane, and reduced responsiveness of the muscle to stimulation by theneuron.

Inhibition of terminal complement activity may be used to blockcomplement-mediated damage resulting from MG and/or rMG. In someembodiments, compounds and/or compositions of the present disclosure maybe used to treat MG and/or rMG. Such methods may be used to inhibit C5activity to reduce or prevent neuromuscular issues associated with MGand/or rMG.

Guillain-Barre Syndrome

In some embodiments, compounds, compositions, e.g., pharmaceuticalcompositions, and methods of the invention may be used to treatGuillain-Barre syndrome (GBS). GBS is an autoimmune disease involvingautoimmune attack of the peripheral nervous system. Compounds,compositions, and/or methods of the invention may be used to reduce orprevent peripheral nervous issues associated with GBS.

Vascular Indications

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to treat vascular indicationsaffecting blood vessels (e.g., arteries, veins, and capillaries). Suchindications may affect blood circulation, blood pressure, blood flow,organ function and/or other bodily functions.

Thrombotic Microangiopathy (TMA)

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to treat and/or preventthrombotic microangiopathy (TMA) and associated diseases.Microangiopathies affect small blood vessels (capillaries) of the bodycausing capillary walls to become thick, weak, and prone to bleeding andslow blood circulation. TMAs tend to lead to the development of vascularthrombi, endothelial cell damage, thrombocytopenia, and hemolysis.Organs such as the brain, kidney, muscles, gastrointestinal system,skin, and lungs may be affected. TMAs may arise from medical operationsand/or conditions that include, but are not limited to, hematopoieticstem cell transplantation (HSCT), renal disorders, diabetes and/or otherconditions. TMAs may be caused by underlying complement systemdysfunction, as described by Meri et al. in European Journal of InternalMedicine, 2013, 24: 496-502, the contents of which are hereinincorporated by reference in their entirety. Generally, TMAs may resultfrom increased levels of certain complement components leading tothrombosis. In some cases, this may be caused by mutations in complementproteins or related enzymes. Resulting complement dysfunction may leadto complement targeting of endothelial cells and platelets leading toincreased thrombosis. In some embodiments, TMAs may be prevented and/ortreated with compounds and compositions of the invention. In some cases,methods of treating TMAs with compounds and compositions of theinvention may be carried out according to those described in USpublication Nos. US2012/0225056 or US2013/0246083, the contents of eachof which are herein incorporated by reference in their entirety.

Disseminated Intravascular Coagulation (DIC)

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatdisseminated intravascular coagulation (DIC) by controlling complementactivation. DIC is a pathological condition where the clotting cascadein blood is widely activated and results in formation of blood clotsespecially in the capillaries. DIC may lead to an obstructed blood flowof tissues and may eventually damage organs. Additionally, DIC affectsthe normal process of blood clotting that may lead to severe bleeding.Compounds and compositions of the invention may be used to treat,prevent or reduce the severity of DIC by modulating complement activity.In some cases compounds and compositions of the invention may be usedaccording to any of the methods of DIC treatment taught in U.S. Pat. No.8,652,477, the contents of which are herein incorporated by reference intheir entirety.

Vasculitis

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatvasculitis. Generally, vasculitis is a disorder related to inflammationof blood vessels, including veins and arteries, characterized by whiteblood cells attacking tissues and causing swelling of the blood vessels.Vasculitis may be associated with an infection, such as in RockyMountain spotted fever, or autoimmunity. An example of autoimmunityassociated vasculitis is Anti-Neutrophil Cytoplasmic Autoantibody (ANCA)vasculitis. ANCA vasculitis is caused by abnormal antibodies attackingthe body's own cells and tissues. ANCAs attack the cytoplasm of certainwhite blood cells and neutrophils, causing them to attack the walls ofthe vessels in certain organs and tissues of the body. ANCA vasculitismay affect skin, lungs, eyes and/or kidney. Studies suggest that ANCAdisease activates an alternative complement pathway and generatescertain complement components that create an inflammation amplificationloop resulting in a vascular injury (Jennette et al. 2013, SeminNephrol. 33(6): 557-64, the contents of which are herein incorporated byreference in their entirety). In some cases, compounds and compositionsof the invention may be used to prevent and/or treat ANCA vasculitis byinhibiting complement activation.

Atypical Hemolytic Uremic Syndrome

In some embodiments, compounds, compositions, e.g., pharmaceuticalcompositions, and/or methods of the present disclosure may be useful fortreatment of atypical hemolytic uremic syndrome (aHUS). aHUS is a raredisease caused by unchecked complement activation characterized by bloodclot formation in small blood vessels. Compositions and methods of theinvention may be useful for reducing or preventing complement activationassociated with aHUS.

Neurological Indications

The compounds and compositions, e.g., pharmaceutical compositions, ofthe invention may be used to prevent, treat and/or ease the symptoms ofneurological indications, including, but not limited toneurodegenerative diseases and related disorders. Neurodegenerationgenerally relates to a loss of structure or function of neurons,including death of neurons. These disorders may be treated by inhibitingthe effect of complement on neuronal cells using compounds andcompositions of the invention. Neurodegenerative related disordersinclude, but are not limited to, Amyelotrophic Lateral Sclerosis (ALS),Multiple Sclerosis (MS), Parkinson's disease and Alzheimer's disease.

Amyotrophic Lateral Sclerosis (ALS)

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent, treat and/or easethe symptoms of ALS. ALS is a fatal motor neuron disease characterizedby the degeneration of spinal cord neurons, brainstems and motor cortex.ALS causes loss of muscle strength leading eventually to a respiratoryfailure. Complement dysfunction may contribute to ALS, and therefore ALSmay be prevented, treated and/or the symptoms may be reduced by therapywith compounds and compositions of the invention targeting complementactivity. In some cases, compounds and compositions of the invention maybe used to promote nerve regeneration. In some cases, compounds andcompositions of the invention may be used as complement inhibitorsaccording to any of the methods taught in US publication No.US2014/0234275 or US2010/0143344, the contents of each of which areherein incorporated by reference in their entirety.

Alzheimer's Disease

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatAlzheimer's disease by controlling complement activity. Alzheimer'sdisease is a chronic neurodegenerative disease with symptoms that mayinclude disorientation, memory loss, mood swings, behavioral problemsand eventually loss of bodily functions. Alzheimer's disease is thoughtto be caused by extracellular brain deposits of amyloid that areassociated with inflammation-related proteins such as complementproteins (Sjoberg et al. 2009. Trends in Immunology. 30(2): 83-90, thecontents of which are herein incorporated by reference in theirentirety). In some cases, compounds and compositions of the inventionmay be used as complement inhibitors according to any of the Alzheimer'streatment methods taught in US publication No. US2014/0234275, thecontents of which are herein incorporated by reference in theirentirety.

Kidney-Related Indications

The compounds and compositions, e.g., pharmaceutical compositions, ofthe invention may be used to treat certain diseases, disorders and/orconditions related to kidneys, in some cases by inhibiting complementactivity. Kidneys are organs responsible for removing metabolic wasteproducts from the blood stream. Kidneys regulate blood pressure, theurinary system, and homeostatic functions and are therefore essentialfor a variety of bodily functions. Kidneys may be more seriouslyaffected by inflammation (as compared to other organs) due to uniquestructural features and exposure to blood. Kidneys also produce theirown complement proteins which may be activated upon infection, kidneydisease, and renal transplantations. In some cases, compounds andcompositions of the invention may be used as complement inhibitors inthe treatment of certain diseases, conditions, and/or disorders of thekidney according to the methods taught by Quigg, J Immunol 2003;171:3319-24, the contents of which are herein incorporated by referencein their entirety.

Lupus Nephritis

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treat lupusnephritis by inhibiting complement activity. Lupus nephritis is a kidneyinflammation caused by an autoimmune disease called systemic lupuserythematosus (SLE). Symptoms of lupus nephritis include high bloodpressure; foamy urine; swelling of the legs, the feet, the hands, or theface; joint pain; muscle pain; fever; and rash. Lupus nephritis may betreated by inhibitors that control complement activity, includingcompounds and compositions of the present invention. Methods andcompositions for preventing and/or treating Lupus nephritis bycomplement inhibition may include any of those taught in US publicationNo. US2013/0345257 or U.S. Pat. No. 8,377,437, the contents of each ofwhich are herein incorporated by reference in their entirety. In someembodiments, compounds and/or compositions of the present disclosure maybe used to prevent and/or treat lupus nephritis by binding C5 andpreventing the progression of kidney disease in lupus nephritis. Thebinding to C5 may prevent and/or treat lupus nephritis by preventing C5activity and blocking complement mediated damage to the kidney cells.

Membranous Glomerulonephritis (MGN)

In some embodiments, compounds and composition, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatmembranous glomerulonephritis (MGN) disorder by inhibiting theactivation of certain complement components. MGN is a disorder of thekidney that may lead to inflammation and structural changes. MGN iscaused by antibodies binding to a soluble antigen in kidney capillaries(glomerulus). MGN may affect kidney functions, such as filtering fluidsand may lead to kidney failure. Compounds and compositions of theinvention may be used according to methods of preventing and/or treatingMGN by complement inhibition taught in U.S. publication No.US2010/0015139 or in International publication No. WO2000/021559, thecontents of each of which are herein incorporated by reference in theirentirety.

Hemodialysis Complications

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatcomplications associated with hemodialysis by inhibiting complementactivation. Hemodialysis is a medical procedure used to maintain kidneyfunction in subjects with kidney failure. In hemodialysis, the removalof waste products such as creatinine, urea, and free water from blood isperformed externally. A common complication of hemodialysis treatment ischronic inflammation caused by contact between blood and the dialysismembrane. Another common complication is thrombosis referring to aformation of blood clots that obstructs the blood circulation. Studieshave suggested that these complications are related to complementactivation. Hemodialysis may be combined with complement inhibitortherapy to provide means of controlling inflammatory responses andpathologies and/or preventing or treating thrombosis in subjects goingthrough hemodialysis due to kidney failure. Methods of using compoundsand compositions of the invention for treatment of hemodialysiscomplications may be carried out according to any of the methods taughtby DeAngelis et al in Immunobiology, 2012, 217(11): 1097-1105 or byKourtzelis et al. Blood, 2010, 116(4):631-639, the contents of each ofwhich are herein incorporated by reference in their entirety.

Ocular Diseases

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatcertain ocular related diseases, disorders and/or conditions. In ahealthy eye the complement system is activated at a low level and iscontinuously regulated by membrane-bound and soluble intraocularproteins that protect against pathogens. Therefore the activation ofcomplement plays an important role in several complications related tothe eye and controlling complement activation may be used to treat suchdiseases. Compounds and compositions of the invention may be used ascomplement inhibitors in the treatment of ocular disease according toany of the methods taught by Jha et al. in Mol Immunol. 2007; 44(16):3901-3908 or in U.S. Pat. No. 8,753,625, the contents of each of whichare herein incorporated by reference in their entirety.

Age-Related Macular Degeneration (AMD)

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatage-related macular degeneration (AMD) by inhibiting ocular complementactivation. AMD is a chronic ocular disease causing blurred centralvision, blind spots in central vision, and/or eventual loss of centralvision. Central vision affects ability to read, drive a vehicle and/orrecognize faces. AMD is generally divided into two types, non-exudative(dry) and exudative (wet). Dry AMD refers to the deterioration of themacula which is the tissue in the center of the retina. Wet AMD refersto the failure of blood vessels under the retina leading to leaking ofblood and fluid. Several human and animal studies have identifiedcomplement proteins that are related to AMD and novel therapeuticstrategies included controlling complement activation pathways, asdiscussed by Jha et al. in Mol Immunol. 2007; 44(16): 3901-8. Methods ofthe invention involving the use of compounds and compositions of theinvention for prevention and/or treatment of AMD may include any ofthose taught in US publication Nos. US2011/0269807 or US2008/0269318,the contents of each of which are herein incorporated by reference intheir entirety.

Corneal Disease

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatcorneal diseases by inhibiting ocular complement activation. Thecomplement system plays an important role in protection of the corneafrom pathogenic particles and/or inflammatory antigens. The cornea isthe outermost front part of the eye covering and protecting the iris,pupil and anterior chamber and is therefore exposed to external factors.Corneal diseases include, but are not limited to, keratoconus,keratitis, ocular herpes and/or other diseases. Corneal complicationsmay cause pain, blurred vision, tearing, redness, light sensitivityand/or corneal scarring. The complement system is critical for cornealprotection, but complement activation may cause damage to the cornealtissue after an infection is cleared as certain complement compounds areheavily expressed. Methods of the present invention for modulatingcomplement activity in the treatment of corneal disease may include anyof those taught by Jha et al. in Mol Immunol. 2007; 44(16): 3901-8, thecontents of which are herein incorporated by reference in theirentirety.

Autoimmune Uveitis

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatuveitis, which is an inflammation of the uveal layer of the eye. Uvea isthe pigmented area of the eye comprising the choroids, iris and ciliarybody of the eye. Uveitis causes redness, blurred vision, pain, synechiaand may eventually cause blindness. Studies have indicated thatcomplement activation products are present in the eyes of patients withautoimmune uveitis and complement plays an important role in diseasedevelopment. In some cases, compounds and compositions of the inventionmay be used to treat and/or prevent uveitis according to any of themethods identified in Jha et al. in Mol Immunol. 2007. 44(16): 3901-8,the contents of which are herein incorporated by reference in theirentirety.

Diabetic Retinopathy

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatdiabetic retinopathy which is a disease caused by changes in retinalblood vessels in diabetic patients. Retinopathy may cause blood vesselswelling and fluid leaking and/or growth of abnormal blood vessels.Diabetic retinopathy affects vision and may eventually lead toblindness. Studies have suggested that activation of complement has animportant role in the development of diabetic retinopathy. In somecases, compounds and compositions of the invention may be used accordingto methods of diabetic retinopathy treatment described in Jha et al. MolImmunol. 2007; 44(16): 3901-8, the contents of which are hereinincorporated by reference in their entirety.

Neuromyelitis Optica (NMO)

In some embodiments, compounds, compositions, e.g., pharmaceuticalcompositions, and/or methods of the invention may be used to treatneuromyelitis optica (NMO). NMO is an autoimmune disease that leads todestruction of the optic nerve. Compounds and/or methods of theinvention may be used to prevent nerve destruction in subjects with NMO.

Sjogren's Syndrome

In some embodiments, compounds, compositions, e.g., pharmaceuticalcompositions, and/or methods of the invention may be used to treatSjorgren's syndrome. Sjorgren's syndrome is an ocular diseasecharacterized by dry eyes that may burn and/or itch. It is an autoimmunedisorder where the immune system targets glands in the eyes and mouthresponsible for moisturizing those regions. Compounds, compositions,and/or methods of the present disclosure may be used to treat and/orreduce the symptoms of Sjorgren's syndrome.

Pre-Eclampsia and HELLP-Syndrome

In some embodiments, compounds and compositions, e.g., pharmaceuticalcompositions, of the invention may be used to prevent and/or treatpre-eclampsia and/or HELLP (abbreviation standing for syndrome featuresof 1) hemolysis, 2) elevated liver enzymes and 3) low platelet count)syndrome by complement inhibitor therapy. Pre-eclampsia is a disorder ofpregnancy with symptoms including elevated blood pressure, swelling,shortness of breath, kidney dysfunction, impaired liver function and/orlow blood platelet count. Pre-eclampsia is typically diagnosed by a highurine protein level and high blood pressure. HELLP syndrome is acombination of hemolysis, elevated liver enzymes and low plateletconditions. Hemolysis is a disease involving rupturing of red bloodcells leading to the release of hemoglobin from red blood cells.Elevated liver enzymes may indicate a pregnancy-induced liver condition.Low platelet levels lead to reduced clotting capability, causing dangerof excessive bleeding. HELLP is associated with a pre-eclampsia andliver disorder. HELLP syndrome typically occurs during the later stagesof pregnancy or after childbirth. It is typically diagnosed by bloodtests indicating the presence of the three conditions it involves.Typically HELLP is treated by inducing delivery.

Studies suggest that complement activation occurs during HELLP syndromeand pre-eclampsia and that certain complement components are present atincreased levels during HELLP and pre-eclampsia. Complement inhibitorsmay be used as therapeutic agents to prevent and/or treat theseconditions. Compounds and compositions of the invention may be usedaccording to methods of preventing and/or treating HELLP andpre-eclampsia taught by Heager et al. in Obstetrics & Gynecology, 1992,79(1): 19-26 or in International publication No. WO201/078622, thecontents of each of which are herein incorporated by reference in theirentirety.

Formulations

In some embodiments, compounds or compositions, e.g., pharmaceuticalcompositions, of the invention are formulated in aqueous solutions. Insome cases, aqueous solutions further include one or more salt and/orone or more buffering agent. Salts may include sodium chloride which maybe included at concentrations of from about 0.05 mM to about 50 mM, fromabout 1 mM to about 100 mM, from about 20 mM to about 200 mM, or fromabout 50 mM to about 500 mM. Further solutions may comprise at least 500mM sodium chloride. In some cases, aqueous solutions include sodiumphosphate. Sodium phosphate may be included in aqueous solutions at aconcentration of from about 0.005 mM to about 5 mM, from about 0.01 mMto about 10 mM, from about 0.1 mM to about 50 mM, from about 1 mM toabout 100 mM, from about 5 mM to about 150 mM, or from about 10 mM toabout 250 mM. In some cases, at least 250 mM sodium phosphateconcentrations are used.

Compositions of the invention may include C5 inhibitors at aconcentration of from about 0.001 mg/mL to about 0.2 mg/mL, from about0.01 mg/mL to about 2 mg/mL, from about 0.1 mg/mL to about 10 mg/mL,from about 0.5 mg/mL to about 5 mg/mL, from about 1 mg/mL to about 20mg/mL, from about 15 mg/mL to about 40 mg/mL, from about 25 mg/mL toabout 75 mg/mL, from about 50 mg/mL to about 200 mg/mL, or from about100 mg/mL to about 400 mg/mL. In some cases, compositions of theinvention include C5 inhibitors at a concentration of at least 400mg/mL.

Compositions of the invention may comprise C5 inhibitors at aconcentration of approximately, about or exactly any of the followingvalues: 0.001 mg/mL, 0.2 mg/mL, 0.01 mg/mL, 2 mg/mL, 0.1 mg/mL, 10mg/mL, 0.5 mg/mL, 5 mg/mL, 1 mg/mL, 20 mg/mL, 15 mg/mL, 40 mg/mL, 25mg/mL, 75 mg/mL, 50 mg/mL, 200 mg/mL, 100 mg/mL, or 400 mg/mL. In somecases, compositions of the invention include C5 inhibitors at aconcentration of at least 40 mg/mL.

In some embodiments, compositions of the invention include aqueouscompositions including at least water and a C5 inhibitor (e.g., a cyclicC5 inhibitor polypeptide). Aqueous C5 inhibitor compositions of theinvention may further include one or more salt and/or one or morebuffering agent. In some cases, aqueous compositions of the inventioninclude water, a cyclic C5 inhibitor polypeptide, a salt, and abuffering agent.

Aqueous C5 inhibitor formulations of the invention may have pH levels offrom about 2.0 to about 3.0, from about 2.5 to about 3.5, from about 3.0to about 4.0, from about 3.5 to about 4.5, from about 4.0 to about 5.0,from about 4.5 to about 5.5, from about 5.0 to about 6.0, from about 5.5to about 6.5, from about 6.0 to about 7.0, from about 6.5 to about 7.5,from about 7.0 to about 8.0, from about 7.5 to about 8.5, from about 8.0to about 9.0, from about 8.5 to about 9.5, or from about 9.0 to about10.0.

In some cases, compounds and compositions of the invention are preparedaccording to good manufacturing practice (GMP) and/or current GMP(cGMP). Guidelines used for implementing GMP and/or cGMP may be obtainedfrom one or more of the US Food and Drug Administration (FDA), the WorldHealth Organization (WHO), and the International Conference onHarmonization (ICH).

Dosage and Administration

For treatment of human subjects, C5 inhibitors (e.g., R5000 and/oractive metabolites or variants thereof) may be formulated aspharmaceutical compositions. Depending on the subject to be treated, themode of administration, and the type of treatment desired (e.g.,prevention, prophylaxis, or therapy) C5 inhibitors may be formulated inways consonant with these parameters. A summary of such techniques isfound in Remington: The Science and Practice of Pharmacy, 21st Edition.Lippincott Williams & Wilkins, (2005); and Encyclopedia ofPharmaceutical Technology, eds. J. Swarbrick and J. C. Boylan,1988-1999, Marcel Dekker, New York, each of which is incorporated hereinby reference.

C5 inhibitors of the present invention (e.g., R5000 and/or activemetabolites or variants thereof) may be provided in a therapeuticallyeffective amount. In some cases, a therapeutically effective amount of aC5 inhibitor of the invention may be achieved by administration of adose of from about 0.1 mg to about 1 mg, from about 0.5 mg to about 5mg, from about 1 mg to about 20 mg, from about 5 mg to about 50 mg, fromabout 10 mg to about 100 mg, from about 20 mg to about 200 mg, or atleast 200 mg of one or more C5 inhibitors.

In some embodiments, subjects may be administered a therapeutic amountof a C5 inhibitor (e.g., R5000 and/or active metabolites or variantsthereof) based on the weight of such subjects. In some cases, C5inhibitors are administered at a dose of from about 0.001 mg/kg to about1.0 mg/kg, from about 0.01 mg/kg to about 2.0 mg/kg, from about 0.05mg/kg to about 5.0 mg/kg, from about 0.03 mg/kg to about 3.0 mg/kg, fromabout 0.01 mg/kg to about 10 mg/kg, from about 0.1 mg/kg to about 2.0mg/kg, from about 0.2 mg/kg to about 3.0 mg/kg, from about 0.4 mg/kg toabout 4.0 mg/kg, from about 1.0 mg/kg to about 5.0 mg/kg, from about 2.0mg/kg to about 4.0 mg/kg, from about 1.5 mg/kg to about 7.5 mg/kg, fromabout 5.0 mg/kg to about 15 mg/kg, from about 7.5 mg/kg to about 12.5mg/kg, from about 10 mg/kg to about 20 mg/kg, from about 15 mg/kg toabout 30 mg/kg, from about 20 mg/kg to about 40 mg/kg, from about 30mg/kg to about 60 mg/kg, from about 40 mg/kg to about 80 mg/kg, fromabout 50 mg/kg to about 100 mg/kg, or at least 100 mg/kg. Such rangesmay include ranges suitable for administration to human subjects. Dosagelevels may be highly dependent on the nature of the condition; drugefficacy; the condition of the patient; the judgment of thepractitioner; and the frequency and mode of administration. In someembodiments, R5000 and/or active metabolites or variants thereof may beadministered at a dose of from about 0.01 mg/kg to about 10 mg/kg. Insome cases R5000 and/or active metabolites or variants thereof may beadministered at a dose of from about 0.1 mg/kg to about 3 mg/kg.

In some cases, C5 inhibitors of the invention (e.g., R5000 and/or activemetabolites or variants thereof) are provided at concentrations adjustedto achieve a desired level the C5 inhibitor in a sample, biologicalsystem, or subject (e.g., plasma level in a subject). In some cases,desired concentrations of C5 inhibitors in a sample, biological system,or subject may include concentrations of from about 0.001 μM to about0.01 μM, from about 0.005 μM to about 0.05 M, from about 0.02 μM toabout 0.2 μM, from about 0.03 μM to about 0.3 τM, from about 0.05 μM toabout 0.5 μM, from about 0.01 μM to about 2.0 μM, from about 0.1 μM toabout 50 μM, from about 0.1 μM to about 10 μM, from about 0.1 μM toabout 5 μM, from about 0.2 μM to about 20 μM, from about 5 μM to about100 μM, or from about 15 μM to about 200 μM. In some cases, desiredconcentrations of C5 inhibitors in subject plasma may be from about 0.1μg/mL to about 1000 μg/mL. The desired concentration of C5 inhibitors insubject plasma may be from about 0.01 μg/mL to about 2 μg/mL, from about0.02 μg/mL to about 4 μg/mL, from about 0.05 μg/mL to about 5 μg/mL,from about 0.1 μg/mL to about 1.0 μg/mL, from about 0.2 μg/mL to about2.0 jμg/mL, from about 0.5 μg/mL to about 5 μg/mL, from about 1 μg/mL toabout 5 μg/mL, from about 2 μg/mL to about 10 μg/mL, from about 3 jμg/mLto about 9 μg/mL, from about 5 μg/mL to about 20 μg/mL, from about 10μg/mL to about 40 μg/mL, from about 30 μg/mL to about 60 μg/mL, fromabout 40 μg/mL to about 80 μg/mL, from about 50 g/mL to about 100 μg/mL,from about 75 μg/mL to about 150 jμg/mL, or at least 150 μg/mL. In otherembodiments, C5 inhibitors are administered at a dose sufficient toachieve a maximum serum concentration (C_(max)) of at least 0.1 μg/mL,at least 0.5 jμg/mL, at least 1 μg/mL, at least 5 μg/mL, at least 10μg/mL, at least 50 g/mL, at least 100 g/mL, or at least 1000 μg/mL.

In some embodiments, doses sufficient to sustain C5 inhibitor levels offrom about 0.1 μg/mL to about 30 μg/mL are provided to reduce hemolysisin a subject by from about 25% to about 99%.

In some embodiments, C5 inhibitors (e.g., R5000 and/or activemetabolites or variants thereof) are administered daily at a dosesufficient to deliver from about 0.1 mg/day to about 60 mg/day per kgweight of a subject. In some cases, the C_(max) achieved with each doseis from about 0.1 μg/mL to about 1000 μg/mL. In such cases, the areaunder the curve (AUC) between doses may be from about 200 μg*hr/mL toabout 10,000 μg*hr/mL.

According to some methods of the invention, C5 inhibitors of theinvention (e.g., R5000 and/or active metabolites or variants thereof)are provided at concentrations needed to achieve a desired effect. Insome cases, compounds and compositions of the invention are provided atan amount necessary to reduce a given reaction or process by half. Theconcentration needed to achieve such a reduction is referred to hereinas the half maximal inhibitory concentration, or “IC₅₀.” Alternatively,compounds and compositions of the invention may be provided at an amountnecessary to increase a given reaction, activity or process by half. Theconcentration needed for such an increase is referred to herein as thehalf maximal effective concentration or “EC₅₀.”

The C5 inhibitors of the invention (e.g., R5000 and/or activemetabolites or variants thereof) may be present in amounts totaling0.1-95% by weight of the total weight of the composition. In some cases,C5 inhibitors are provided by intravenous (IV) administration. In somecases. C5 inhibitors are provided by subcutaneous (SC) administration.

SC administration of C5 inhibitors of the invention (e.g., R5000 and/oractive metabolites or variants thereof) may, in some cases, provideadvantages over IV administration. SC administration may allow patientsto provide self-treatment. Such treatment may be advantageous in thatpatients could provide treatment to themselves in their own home,avoiding the need to travel to a provider or medical facility. Further,SC treatment may allow patients to avoid long-term complicationsassociated with IV administration, such as infections, loss of venousaccess, local thrombosis, and hematomas. In some embodiments, SCtreatment may increase patient compliance, patient satisfaction, qualityof life, reduce treatment costs and/or drug requirements.

In some cases, daily SC administration provides steady-state C5inhibitor concentrations that are reached within 1-3 doses, 2-3 doses,3-5 doses, or 5-10 doses. In some cases, daily SC doses of 0.1 mg/kg mayachieve sustained C5 inhibitor levels greater than or equal to 2.5 μg/mLand/or inhibition of complement activity of greater than 90%.

C5 inhibitors of the invention (e.g., R5000 and/or active metabolites orvariants thereof) may exhibit slow absorption kinetics (time to maximumobserved concentration of greater than 4-8 hours) and highbioavailability (from about 75% to about 100%) after SC administration.

In some embodiments, dosage and/or administration are altered tomodulate the half-life (t_(1/2)) of C5 inhibitor levels in a subject orin subject fluids (e.g., plasma). In some cases, t_(1/2) is at least 1hour, at least 2 hrs, at least 4 hrs, at least 6 hrs, at least 8 hrs, atleast 10 hrs, at least 12 hrs, at least 16 hrs, at least 20 hrs, atleast 24 hrs, at least 36 hrs, at least 48 hrs, at least 60 hrs, atleast 72 hrs, at least 96 hrs, at least 5 days, at least 6 days, atleast 7 days, at least 8 days, at least 9 days, at least 10 days, atleast 11 days, at least 12 days, at least 2 weeks, at least 3 weeks, atleast 4 weeks, at least 5 weeks, at least 6 weeks, at least 7 weeks, atleast 8 weeks, at least 9 weeks, at least 10 weeks, at least 11 weeks,at least 12 weeks, or at least 16 weeks.

In some embodiments, C5 inhibitors of the invention (e.g., R5000 and/oractive metabolites or variants thereof) may exhibit long terminalt_(1/2). Extended terminal t_(1/2) may be due to extensive targetbinding and/or additional plasma protein binding. In some cases, C5inhibitors of the invention exhibit t_(1/2) values greater than 24 hoursin both plasma and whole blood. In some cases, C5 inhibitors do not losefunctional activity after incubation in human whole blood at 37° C. for16 hours.

In some embodiments, dosage and/or administration are altered tomodulate the steady state volume of distribution of C5 inhibitors. Insome cases, the steady state volume of distribution of C5 inhibitors isfrom about 0.1 mL/kg to about 1 mL/kg, from about 0.5 mL/kg to about 5mL/kg, from about 1 mL/kg to about 10 mL/kg, from about 5 mL/kg to about20 mL/kg, from about 15 mL/kg to about 30 mL/kg, from about 10 mL/kg toabout 200 mL/kg, from about 20 mL/kg to about 60 mL/kg, from about 30mL/kg to about 70 mL/kg, from about 50 mL/kg to about 200 mL/kg, fromabout 100 mL/kg to about 500 mL/kg, or at least 500 mL/kg. In somecases, the dosage and/or administration of C5 inhibitors is adjusted toensure that the steady state volume of distribution is equal to at least50% of total blood volume. In some embodiments, C5 inhibitordistribution may be restricted to the plasma compartment.

In some embodiments, C5 inhibitors of the invention (e.g., R5000 and/oractive metabolites or variants thereof) exhibit a total clearance rateof from about 0.001 mL/hr/kg to about 0.01 mL/hr/kg, from about 0.005mL/hr/kg to about 0.05 mL/hr/kg, from about 0.01 mL/hr/kg to about 0.1mL/kg, from about 0.05 mL/hr/kg to about 0.5 mL/hr/kg, from about 0.1mL/hr/kg to about 1 mL/hr/kg, from about 0.5 mL/hr/kg to about 5mL/hr/kg, from about 0.04 mL/hr/kg to about 4 mL/hr/kg, from about 1mL/hr/kg to about 10 mL/hr/kg, from about 5 mL/hr/kg to about 20mL/hr/kg, from about 15 mL/hr/kg to about 30 mL/hr/kg, or at least 30mL/hr/kg.

Time periods for which maximum concentration of C5 inhibitors insubjects (e.g., in subject serum) are maintained (Tax values) may beadjusted by altering dosage and/or administration (e.g., subcutaneousadministration). In some cases, C5 inhibitors have T_(max) values offrom about 1 min to about 10 min, from about 5 min to about 20 min, fromabout 15 min to about 45 min, from about 30 min to about 60 min, fromabout 45 min to about 90 min, from about 1 hour to about 48 hrs, fromabout 2 hrs to about 10 hrs, from about 5 hrs to about 20 hrs, fromabout 10 hrs to about 60 hrs, from about 1 day to about 4 days, fromabout 2 days to about 10 days, or at least 10 days.

In some embodiments, C5 inhibitors of the invention (e.g., R5000 and/oractive metabolites or variants thereof) may be administered withoutoff-target effects. In some cases, C5 inhibitors of the invention do notinhibit hERG (human ether-a-go-go related gene), even withconcentrations less than or equal to 300 μM. SC injection of C5inhibitors of the invention with dose levels up to 10 mg/kg may be welltolerated and not result in any adverse effects of the cardiovascularsystem (e.g., elevated risk of prolonged ventricular repolarization)and/or respiratory system.

C5 inhibitor doses may be determined using the no observed adverseeffect level (NOAEL) observed in another species. Such species mayinclude, but are not limited to monkeys, rats, rabbits, and mice. Insome cases, human equivalent doses (HEDs) may be determined byallometric scaling from NOAELs observed in other species. In some cases,HEDs result in therapeutic margins of from about 2 fold to about 5 fold,from about 4 fold to about 12 fold, from about 5 fold to about 15 fold,from about 10 fold to about 30 fold, or at least 30 fold. In some cases,therapeutic margins are determined by using exposure in primates andestimated human C_(max) levels in humans.

In some embodiments, C5 inhibitors of the invention allow for a rapidwashout period in cases of infection where prolonged inhibition of thecomplement system prove detrimental.

C5 inhibitor administration according to the invention may be modifiedto reduce potential clinical risks to subjects. Infection with Neisseriameningitidis is a known risk of C5 inhibitors, including eculizumab. Insome cases, risk of infection with Neisseria meningitides is minimizedby instituting one or more prophylactic steps. Such steps may includethe exclusion of subjects who may already be colonized by thesebacteria. In some cases, prophylactic steps may include coadministrationwith one or more antibiotics. In some cases, ciprofloxacin may becoadministered. In some cases, ciprofloxacin may be coadministeredorally at a dose of from about 100 mg to about 1000 mg (e.g., 500 mg).

In some embodiments, C5 inhibitor administration may be carried outusing an auto-injector device. Such devices may allow forself-administration (e.g., daily administration).

In some embodiments, R5000 and/or active metabolites or variants thereofmay be co-administered with eculizumab. Co-administration may be carriedout to reduce residual C5 activity associated with eculizumab treatmentalone (e.g., due to incomplete inhibition).

Dosage Frequency

In some embodiments, C5 inhibitors of the invention (e.g., R5000 and/oractive metabolites or variants thereof) are administered at a frequencyof every hour, every 2 hrs, every 4 hrs, every 6 hrs, every 12 hrs,every 18 hrs, every 24 hrs, every 36 hrs, every 72 hrs, every 84 hrs,every 96 hrs, every 5 days, every 7 days, every 10 days, every 14 days,every week, every two weeks, every 3 weeks, every 4 weeks, every month,every 2 months, every 3 months, every 4 months, every 5 months, every 6months, every year, or at least every year. In some cases, C5 inhibitorsare administered once daily or administered as two, three, or moresub-doses at appropriate intervals throughout the day.

In some embodiments, C5 inhibitors are administered in multiple dailydoses. In some cases, C5 inhibitors are administered daily for 7 days.In some cases, C5 inhibitors are administered daily for 7 to 100 days.In some cases, C5 inhibitors are administered daily for at least 100days. In some cases, C5 inhibitors are administered daily for anindefinite period.

C5 inhibitors delivered intravenously may be delivered by infusion overa period of time, such as over a 5 minute, 10 minute, 15 minute, 20minute, or 25 minute period. The administration may be repeated, forexample, on a regular basis, such as hourly, daily, weekly, biweekly(i.e., every two weeks), for one month, two months, three months, fourmonths, or more than four months. After an initial treatment regimen,treatments may be administered on a less frequent basis. For example,after biweekly administration for three months, administration may berepeated once per month, for six months or a year or longer.Administration C5 inhibitor may reduce, lower, increase or alter bindingor any physiologically deleterious process (e.g., in a cell, tissue,blood, urine or other compartment of a patient) by at least 10%, atleast 15%, at least 20%, at least 25%, at least 30%, at least 40%, atleast 50%, at least 60%, at least 70%, at least 80% or at least 90% ormore.

Before administration of a full dose of the C5 inhibitor and/or C5inhibitor composition, patients can be administered a smaller dose, suchas 5% of a full dose, and monitored for adverse effects, such as anallergic reaction or infusion reaction, or for elevated lipid levels orblood pressure. In another example, the patient can be monitored forunwanted immunostimulatory effects, such as increased cytokine (e.g.,TNF-alpha, IL-1, IL-6, or IL-10) levels.

Genetic predisposition plays a role in the development of some diseasesor disorders. Therefore, a patient in need of a C5 inhibitor may beidentified by taking a family history, or, for example, screening forone or more genetic markers or variants. A healthcare provider, such asa doctor, nurse, or family member, may analyze family history beforeprescribing or administering a therapeutic composition of the presentinvention.

C5 Assays

In some embodiments, the present disclosure provides compounds andmethods for the detection of C5 and/or C5-associating factors insamples. With some methods, total C5 is detected. Total C5 may includeboth free C5 and C5 associated with one or more C5-associating factors.C5-associating factors may include antibodies (e.g., eculizumab orsimilar antibody binding to a similar epitope). According to suchembodiments, samples may be added to a substrate, wherein the substrateincludes a capture agent that associates with C5. The capture agent maybind to C5 on a region of C5 that is non-overlapping with a portion ofthe C5 protein recognized by a C5-associating factor. Both free C5 andC5 associated with one or more C5-associating factors may be captured bycapture agents to facilitate detection using one or more detectionagents. As used herein, a “detection agent” is any factor thatfacilitates recognition of an analyte, interaction, reaction, process,or event. In some embodiments, detection agents are detectionantibodies. Detection agents may bind to an analyte to facilitaterecognition of the analyte's presence or absence. Detection agents usedto detect capture of free C5 may bind to C5 on a region that isnon-overlapping with a region bound by the capture agent or aC5-associating factor. Detection agents used to detect capture of C5associated with one or more C5-associating factors may bind to theC5-associating factor. Detection agents may include a detectable label.

As used herein, the term “detectable label” refers to one or moremarkers, signals, or moieties which are attached, incorporated, orassociated with another entity, which markers, signals or moieties arereadily detected by methods known in the art including, but not limitedto, radiography, fluorescence, chemiluminescence, enzymatic activity,absorbance and the like. Detectable labels may include, but are notlimited to, radioisotopes, fluorophores, chromophores, enzymes, dyes,metal ions, ligands (e.g., biotin, avidin, streptavidin, and haptens,such as digoxigenin), quantum dots, and the like. Detectable labels maybe located at any position of the entity with which they are attached,incorporated or associated. For example, when attached, incorporated in,or associated with a peptide or protein, detectable labels may be withinthe amino acids, the peptides, or proteins, or located at the N- orC-termini.

In some embodiments, detection agents may be detected using a secondarydetection agent that binds to the detection agent or a detectable labelassociated with the detection agent. The secondary detection agent mayinclude an antibody. The secondary detection agent may be associatedwith a detectable label to facilitate detection (e.g., throughfluorescent, radiographic, colorimetric, enzymatic, or other detectionmethods). In one embodiment, the detection agent includes digoxigenin.The digoxigenin may be detected using an anti-digoxigenin antibody.

Assay substrates may include surfaces capable of retaining captureagents. Capture agents may be immobilized to substrates, e.g., throughcovalent or non-covalent interactions. In some embodiments, captureagents are biotinylated to facilitate substrate immobilization withsubstrates having a biotin-interacting compound (e.g., avidin,neutravidin, or streptavidin). Substrates may include, but are notlimited to, assay plates. In some embodiments, substrates are beads.

C5 capture agents may include any compounds capable of associating withC5. In some embodiments, capture agents include peptides orpeptide-based compounds. Capture agents may include R5000 or variantsthereof. In some assays, a variant of R5000 is used wherein the variantincludes an N-terminal biotinylated PEG moiety to facilitate substrateimmobilization. Some R5000 variants may further include substitution ofthe C-terminal lysine with another compound. The compound may be anotheramino acid, for example, any natural or non-natural amino acid. SomeR5000 variants have substitutions of the C-terminal lysine withnorvaline.

In some embodiments, the present disclosure provides a method ofmeasuring C5 or C5 levels in a sample by immobilizing a capture agent ona substrate, wherein the capture agent binds to a site on C5 that isdistinct from the eculizumab binding site; contacting the substrate withthe sample, wherein the immobilized capture agent binds to C5 in thesample; contacting the substrate with a detection agent (e.g., anantibody), and measuring the presence or level of the detection agent asan indicator of C5 levels in the sample. The detection agent may includea detectable label. The detection agent may be detected using asecondary detection agent. The detection agent may be an anti-C5antibody (e.g., eculizumab or non-eculizumab anti-C5 antibody). Themethod may include contacting the substrate with a second detectionagent (e.g., an antibody), wherein the second detection agent binds to aC5-associated factor (e.g., eculizumab). Measurement of the level of thesecond detection antibody bound to the substrate may be carried out asan indicator of C5-associated factor levels in the sample. In someembodiments, both free C5 levels and eculizumab-associated C5 levels aremeasured using assays disclosed herein. The levels may be combinedlevels, yielding total C5 levels in samples having both forms. In someembodiments, fee C5 levels and eculizumab-associated C5 levels aredistinguished.

In some embodiments, the present disclosure provides methods formeasuring free eculizumab levels in a sample by immobilizing a captureagent on a substrate, where the capture agent binds to a site on C5 thatis distinct from the eculizumab binding site, contacting the substratewith an excess of C5 to form a C5-capture agent complex, wherein theC5-capture agent complex comprises immobilized C5; contacting thesubstrate with the sample, wherein the immobilized C5 binds toeculizumab in the sample; contacting the substrate with a detectionagent, wherein the detection agent binds to eculizumab; and measuringthe level of bound detection agent as an indicator of free eculizumablevels in the sample. Capture agents may include R5000 or variantsthereof. In some assays, a variant of R5000 is used wherein the variantincludes an N-terminal biotinylated PEG moiety to facilitate substrateimmobilization. The R5000 variant may include a substitution of theC-terminal lysine with another compound. The compound may be anotheramino acid, for example, any natural or non-natural amino acid. TheR5000 variant may have a substitution of the C-terminal lysine withnorvaline. The detection agent may be an antibody. The detection agentmay include a detectable label or be detected using a secondarydetection agent.

III. Kits

Any of the C5 inhibitors described herein (e.g., R5000 and/or activemetabolites or variants thereof) may be provided as part of a kit. In anon-limiting example, C5 inhibitors may be included in a kit fortreating a disease. The kit may include a vial of sterile, dry C5inhibitor powder, sterile solution for dissolving the dried powder, anda syringe for infusion set for administering the C5 inhibitor.

When C5 inhibitors are provided as a dried powder it is contemplatedthat between 10 micrograms and 1000 milligrams of C5 inhibitor, or atleast or at most those amounts are provided in kits of the invention

Typical kits may include at least one vial, test tube, flask, bottle,syringe and/or other container or device, into which the C5 inhibitorformulations are placed, preferably, suitably allocated. Kits may alsoinclude one or more secondary containers with sterile, pharmaceuticallyacceptable buffer and/or other diluent.

In some embodiments, compounds or compositions of the invention areprovided in borosilicate vials. Such vials may include a cap (e.g., arubber stopper). In some cases, caps include FLUROTEC® coated rubberstoppers. Caps may be secured in place with an overseal, including, butnot limited to an aluminum flip-off overseal.

Kits may further include instructions for employing the kit componentsas well the use of any other reagent not included in the kit.Instructions may include variations that can be implemented.

IV. Definitions

Bioavailability: As used herein, the term “bioavailability” refers tothe systemic availability of a given amount of a compound (e.g., C5inhibitor) administered to a subject. Bioavailability can be assessed bymeasuring the area under the curve (AUC) or the maximum serum or plasmaconcentration (C_(max)) of the unchanged form of a compound followingadministration of the compound to a subject. AUC is a determination ofthe area under the curve when plotting the serum or plasma concentrationof a compound along the ordinate (Y-axis) against time along theabscissa (X-axis). Generally, the AUC for a particular compound can becalculated using methods known to those of ordinary skill in the artand/or as described in G. S. Banker, Modern Pharmaceutics, Drugs and thePharmaceutical Sciences, v. 72, Marcel Dekker, New York, Inc., 1996, thecontents of which are herein incorporated by reference in theirentirety.

Biological system: As used herein, the term “biological system” refersto a cell, a group of cells, a tissue, an organ, a group of organs, anorganelle, a biological fluid, a biological signaling pathway (e.g., areceptor-activated signaling pathway, a charge-activated signalingpathway, a metabolic pathway, a cellular signaling pathway, etc.), agroup of proteins, a group of nucleic acids, or a group of molecules(including, but not limited to biomolecules) that carry out at least onebiological function or biological task within cellular membranes,cellular compartments, cells, cell cultures, tissues, organs, organsystems, organisms, multicellular organisms, biological fluids, or anybiological entities. In some embodiments, biological systems are cellsignaling pathways comprising intracellular and/or extracellularsignaling biomolecules. In some embodiments, biological systems includeproteolytic cascades (e.g., the complement cascade).

Buffering agent: As used herein, the term “buffering agent” refers to acompound used in a solution for the purposes of resisting changes in pH.Such compounds may include, but are not limited to acetic acid, adipicacid, sodium acetate, benzoic acid, citric acid, sodium benzoate, maleicacid, sodium phosphate, tartaric acid, lactic acid, potassiummetaphosphate, glycine, sodium bicarbonate, potassium phosphate, sodiumcitrate, and sodium tartrate.

Clearance rate: As used herein, the term “clearance rate” refers to thevelocity at which a particular compound is cleared from a biologicalsystem or fluid.

Compound: As used herein, the term “compound,” refers to a distinctchemical entity. In some embodiments, a particular compound may exist inone or more isomeric or isotopic forms (including, but not limited tostereoisomers, geometric isomers and isotopes). In some embodiments, acompound is provided or utilized in only a single such form. In someembodiments, a compound is provided or utilized as a mixture of two ormore such forms (including, but not limited to a racemic mixture ofstereoisomers). Those of skill in the art will appreciate that somecompounds exist in different forms, show different properties and/oractivities (including, but not limited to biological activities). Insuch cases it is within the ordinary skill of those in the art to selector avoid particular forms of a compound for use in accordance with thepresent invention. For example, compounds that contain asymmetricallysubstituted carbon atoms can be isolated in optically active or racemicforms.

Cyclic or Cyclized: As used herein, the term “cyclic” refers to thepresence of a continuous loop. Cyclic molecules need not be circular,only joined to form an unbroken chain of subunits. Cyclic polypeptidesmay include a “cyclic loop,” formed when two amino acids are connectedby a bridging moiety. The cyclic loop comprises the amino acids alongthe polypeptide present between the bridged amino acids. Cyclic loopsmay comprise 2, 3, 4, 5, 6, 7, 8, 9, 10 or more amino acids.

Downstream event: As used herein, the term “downstream” or “downstreamevent,” refers to any event occurring after and/or as a result ofanother event. In some cases, downstream events are events occurringafter and as a result of C5 cleavage and/or complement activation. Suchevents may include, but are not limited to generation of C5 cleavageproducts, activation of MAC, hemolysis, and hemolysis-related disease(e.g., PNH).

Equilibrium dissociation constant: As used herein, the term “equilibriumdissociation constant” or “K_(D)” refers to a value representing thetendency of two or more agents (e.g., two proteins) to reversiblyseparate. In some cases, K_(D) indicates a concentration of a primaryagent at which half of the total levels of a secondary agent areassociated with the primary agent.

Half-life: As used herein, the term “half-life” or “t_(1/2)” refers tothe time it takes for a given process or compound concentration to reachhalf of a final value. The “terminal half-life” or “terminal t_(1/2)”refers to the time needed for the plasma concentration of a factor to bereduced by half after the concentration of the factor has reached apseudo-equilibrium.

Hemolysis: As used herein, the term “hemolysis” refers to thedestruction of red blood cells.

Identity: As used herein, the term “identity,” when referring topolypeptides or nucleic acids, refers to a comparative relationshipbetween sequences. The term is used to describe the degree of sequencerelatedness between polymeric sequences, and may include the percentageof matching monomeric components with gap alignments (if any) addressedby a particular mathematical model or computer program (i.e.,“algorithms”). Identity of related polypeptides can be readilycalculated by known methods. Such methods include, but are not limitedto, those described previously by others (Lesk, A. M., ed.,Computational Molecular Biology, Oxford University Press, New York,1988; Smith. D. W., ed., Biocomputing: Informatics and Genome Projects,Academic Press, New York, 1993; Griffin, A. M. et al., ed., ComputerAnalysis of Sequence Data, Part 1, Humana Press, New Jersey, 1994; vonHeinje, G., Sequence Analysis in Molecular Biology, Academic Press,1987: Gribskov, M. et al., ed., Sequence Analysis Primer, M. StocktonPress, New York, 1991; and Carillo et al., Applied Math, SIAM J, 1988,48, 1073).

Inhibitor: As used herein, the term “inhibitor” refers to any agent thatblocks or causes a reduction in the occurrence of a specific event;cellular signal; chemical pathway; enzymatic reaction; cellular process;interaction between two or more entities; biological event; disease;disorder; or condition.

Initial loading dose: As used herein, an “initial loading dose” refersto a first dose of a therapeutic agent that may differ from one or moresubsequent doses. Initial loading doses may be used to achieve aninitial concentration of a therapeutic agent or level of activity beforesubsequent doses are administered.

Intravenous: As used herein, the term “intravenous” refers to the areawithin a blood vessel. Intravenous administration typically refers todelivery of a compound into the blood through injection in a bloodvessel (e.g., vein).

In vitro: As used herein, the term “in vitro” refers to events thatoccur in an artificial environment (e.g., in a test tube or reactionvessel, in cell culture, in a Petri dish, etc.), rather than within anorganism (e.g., animal, plant, or microbe).

In vivo: As used herein, the term “in vivo” refers to events that occurwithin an organism (e.g., animal, plant, or microbe or cell or tissuethereof).

Lactam bridge: As used herein, the term “lactam bridge” refers to anamide bond that forms a bridge between chemical groups in a molecule. Insome cases, lactam bridges are formed between amino acids in apolypeptide.

Linker: The term “linker” as used herein refers to a group of atoms(e.g., 10-1,000 atoms), molecule(s), or other compounds used to join twoor more entities. Linkers may join such entities through covalent ornon-covalent (e.g., ionic or hydrophobic) interactions. Linkers mayinclude chains of two or more polyethylene glycol (PEG) units. In somecases, linkers may be cleavable.

Minute volume: As used herein, the term “minute volume” refers to thevolume of air inhaled or exhaled from a subject's lungs per minute.

Non-proteinogenic: As used herein, the term “non-proteinogenic” refersto any unnatural proteins, such as those with unnatural components, suchas unnatural amino acids.

Patient: As used herein, “patient” refers to a subject who may seek orbe in need of treatment, requires treatment, is receiving treatment,will receive treatment, or a subject who is under the care of a trainedprofessional for a particular disease or condition.

Pharmaceutical composition: As used herein, the term “pharmaceuticalcomposition” refers to a composition comprising at least one activeingredient (e.g., a C5 inhibitor) in a form and amount that permits theactive ingredient to be therapeutically effective.

Pharmaceutically acceptable: The phrase “pharmaceutically acceptable” isemployed herein to refer to those compounds, materials, compositions,and/or dosage forms which are, within the scope of sound medicaljudgment, suitable for use in contact with the tissues of human beingsand animals without excessive toxicity, irritation, allergic response,or other problem or complication, commensurate with a reasonablebenefit/risk ratio.

Pharmaceutically acceptable excipients: The phrase “pharmaceuticallyacceptable excipient,” as used herein, refers any ingredient other thanactive agents (e.g., active agent R5000 and/or active metabolitesthereof or variants thereof) present in a pharmaceutical composition andhaving the properties of being substantially nontoxic andnon-inflammatory in a patient. In some embodiments, a pharmaceuticallyacceptable excipient is a vehicle capable of suspending or dissolvingthe active agent. Excipients may include, for example: antiadherents,antioxidants, binders, coatings, compression aids, disintegrants, dyes(colors), emollients, emulsifiers, fillers (diluents), film formers orcoatings, flavors, fragrances, glidants (flow enhancers), lubricants,preservatives, printing inks, sorbents, suspensing or dispersing agents,sweeteners, and waters of hydration. Exemplary excipients include, butare not limited to: butylated hydroxytoluene (BHT), calcium carbonate,calcium phosphate (dibasic), calcium stearate, croscarmellose,crosslinked polyvinyl pyrrolidone, citric acid, crospovidone, cysteine,ethylcellulose, gelatin, hydroxypropyl cellulose, hydroxypropylmethylcellulose, lactose, magnesium stearate, maltitol, mannitol,methionine, methylcellulose, methyl paraben, microcrystalline cellulose,polyethylene glycol, polyvinyl pyrrolidone, povidone, pregelatinizedstarch, propyl paraben, retinyl palmitate, shellac, silicon dioxide,sodium carboxymethyl cellulose, sodium citrate, sodium starch glycolate,sorbitol, starch (corn), stearic acid, sucrose, talc, titanium dioxide,vitamin A, vitamin E, vitamin C, and xylitol.

Plasma compartment: As used herein, the term “plasma compartment” refersto intravascular space occupied by blood plasma.

Salt: As used herein, the term “salt” refers to a compound made up of acation with a bound anion. Such compounds may include sodium chloride(NaCl) or other classes of salts including, but not limited to acetates,chlorides, carbonates, cyanides, nitrites, nitrates, sulfates, andphosphates.

Sample: As used herein, the term “sample” refers to an aliquot orportion taken from a source and/or provided for analysis or processing.In some embodiments, a sample is from a biological source such as atissue, cell or component part (e.g., a body fluid, including but notlimited to blood, mucus, lymphatic fluid, synovial fluid, cerebrospinalfluid, saliva, amniotic fluid, amniotic cord blood, urine, vaginal fluidand semen). In some embodiments, a sample may be or comprise ahomogenate, lysate or extract prepared from a whole organism or a subsetof its tissues, cells or component parts, or a fraction or portionthereof, including but not limited to, for example, plasma, serum,spinal fluid, lymph fluid, the external sections of the skin,respiratory, intestinal, and genitourinary tracts, tears, saliva, milk,blood cells, tumors, or organs. In some embodiments, a sample is orcomprises a medium, such as a nutrient broth or gel, which may containcellular components, such as proteins. In some embodiments, a “primary”sample is an aliquot of the source. In some embodiments, a primarysample is subjected to one or more processing (e.g., separation,purification, etc.) steps to prepare a sample for analysis or other use.

Subcutaneous: As used herein, the term “subcutaneous” refers to thespace underneath the skin. Subcutaneous administration is delivery of acompound beneath the skin.

Subject: As used herein, the term “subject” refers to any organism towhich a compound in accordance with the invention may be administered,e.g., for experimental, diagnostic, prophylactic, and/or therapeuticpurposes. Typical subjects include animals (e.g., mammals such as mice,rats, rabbits, porcine subjects, non-human primates, and humans).

Substantially: As used herein, the term “substantially” refers to thequalitative condition of exhibiting total or near-total extent or degreeof a characteristic or property of interest. One of ordinary skill inthe biological arts will understand that biological and chemicalphenomena rarely, if ever, go to completion and/or proceed tocompleteness or achieve or avoid an absolute result. The term“substantially” is therefore used herein to capture the potential lackof completeness inherent in many biological and chemical phenomena.

Therapeutically effective amount: As used herein, the term“therapeutically effective amount” means an amount of an agent to bedelivered (e.g., C5 inhibitor) that is sufficient, when administered toa subject suffering from or susceptible to a disease, disorder, and/orcondition, to treat, improve symptoms of, diagnose, prevent, and/ordelay the onset of the disease, disorder, and/or condition.

Tidal volume: As used herein, the term “tidal volume” refers to thenormal lung volume of air displaced between breaths (in the absence ofany extra effort).

T_(max): As used herein, the term “T_(max)” refers to the time periodfor which maximum concentration of a compound in a subject or fluid ismaintained.

Treating: As used herein, the term “treating” refers to partially orcompletely alleviating, ameliorating, improving, relieving, delayingonset of, inhibiting progression of, reducing severity of, and/orreducing incidence of one or more symptoms or features of a particulardisease, disorder, and/or condition. Treatment may be administered to asubject who does not exhibit signs of a disease, disorder, and/orcondition and/or to a subject who exhibits only early signs of adisease, disorder, and/or condition for the purpose of decreasing therisk of developing pathology associated with the disease, disorder,and/or condition.

Treatment dose: As used herein, “treatment dose” refers to one or moredoses of a therapeutic agent administered in the course of addressing oralleviating a therapeutic indication. Treatment doses may be adjusted tomaintain a desired concentration or level of activity of a therapeuticagent in a body fluid or biological system.

Volume of distribution: As used herein, the term “volume ofdistribution” or “V_(dist)” refers to a fluid volume required to containthe total amount of a compound in the body at the same concentration asin the blood or plasma. The volume of distribution may reflect theextent to which a compound is present in the extravascular tissue. Alarge volume of distribution reflects the tendency of a compound to bindto tissue components compared with plasma protein components. In aclinical setting, V_(dist) can be used to determine a loading dose of acompound to achieve a steady state concentration of that compound.

V. Equivalents and Scope

While various embodiments of the invention have been particularly shownand described, it will be understood by those skilled in the art thatvarious changes in form and details may be made therein withoutdeparting from the spirit and scope of the invention as defined by theappended claims.

Those skilled in the art will recognize, or be able to ascertain usingno more than routine experimentation, many equivalents to the specificembodiments in accordance with the invention described herein. The scopeof the present invention is not intended to be limited to the abovedescription, but rather is as set forth in the appended claims.

In the claims, articles such as “a,” “an,” and “the” may mean one ormore than one unless indicated to the contrary or otherwise evident fromthe context. Claims or descriptions that include “or” between one ormore members of a group are considered satisfied if one, more than one,or all of the group members are present in, employed in, or otherwiserelevant to a given product or process unless indicated to the contraryor otherwise evident from the context. The invention includesembodiments in which exactly one member of the group is present in,employed in, or otherwise relevant to a given product or process. Theinvention includes embodiments in which more than one, or all of thegroup members are present in, employed in, or otherwise relevant to agiven product or process.

It is also noted that the term “comprising” is intended to be open andpermits but does not require the inclusion of additional elements orsteps. When the term “comprising” is used herein, the terms “consistingof” and “or including” are thus also encompassed and disclosed.

Where ranges are given, endpoints are included. Furthermore, it is to beunderstood that unless otherwise indicated or otherwise evident from thecontext and understanding of one of ordinary skill in the art, valuesthat are expressed as ranges can assume any specific value or subrangewithin the stated ranges in different embodiments of the invention, tothe tenth of the unit of the lower limit of the range, unless thecontext clearly dictates otherwise.

In addition, it is to be understood that any particular embodiment ofthe present invention that falls within the prior art may be explicitlyexcluded from any one or more of the claims. Since such embodiments aredeemed to be known to one of ordinary skill in the art, they may beexcluded even if the exclusion is not set forth explicitly herein. Anyparticular embodiment of the compositions of the invention (e.g., anynucleic acid or protein encoded thereby; any method of production; anymethod of use; etc.) can be excluded from any one or more claims, forany reason, whether or not related to the existence of prior art.

All cited sources, for example, references, publications, databases,database entries, and art cited herein, are incorporated into thisapplication by reference, even if not expressly stated in the citation.In case of conflicting statements of a cited source and the instantapplication, the statement in the instant application shall control.

Section and table headings are not intended to be limiting.

EXAMPLES Example 1. Preparation of R5000 Aqueous Solution

Polypeptides were synthesized using standard solid-phase Fmoc/tBumethods. The synthesis was performed on a Liberty automated microwavepeptide synthesizer (CEM, Matthews N.C.) using standard protocols withRink amide resin, although other automated synthesizers withoutmicrowave capability may also be used. All amino acids were obtainedfrom commercial sources. The coupling reagent used was2-(6-chloro-1-H-benzotriazole-1yl)-1,1,3,3,-tetramethylaminiumhexafluorophosphate (HCTU) and the base was diisopropylethylamine(DIEA). Polypeptides were cleaved from resin with 95% TFA, 2.5% TIS and2.5% water for 3 hours and isolated by precipitation with ether. Thecrude polypeptides were purified on a reverse phase preparative HPLCusing a C18 column, with an acetonitrile/water 0.10/TFA gradient from20%-50% over 30 min. Fractions containing pure polypeptides werecollected and lyophilized and all polypeptides were analyzed by LC-MS.

R5000 (SEQ ID NO: 1) was prepared as a cyclic peptide containing 15amino acids (4 of which are unnatural amino acids), an acetylatedN-terminus, and a C-terminal carboxylic acid. The C-terminal lysine ofthe core peptide has a modified side chain, forming aN-ε-(PEG24-γ-glutamic acid-N-α-hexadecanoyl) lysine reside. Thismodified side chain includes a polyethyleneglycol spacer (PEG24)attached to an L-γ glutamic acid residue that is derivatized with apalmitoyl group. The cyclization of R5000 is via a lactam bridge betweenthe side-chains of L-Lys 1 and L-Asp6. All of the amino acids in R5000are L-amino acids. R5000 has a molecular weight of 3562.23 g/mol and achemical formula of C₁₇₂H₂₇₈N₂₄O₃₅.

Like eculizumab, R5000 blocks the proteolytic cleavage of C5 into C5aand C5b. Unlike eculizumab, R5000 can also bind to C5b and block C6binding which prevents the subsequent assembly of the MAC.

R5000 was prepared as an aqueous solution for injection containing 40mg/mL of R5000 in a formulation of 50 mM sodium phosphate and 76 mMsodium chloride at a pH of 7.0. The resulting composition was used toprepare a medicinal product, in accordance with current GoodManufacturing Practices (cGMPs), the medicinal product including a 1 mlsyringe with a 29 gauge, ½ inch staked needle placed within aself-administration device.

Example 2. R5000 Administration and Storage

R5000 is administered by subcutaneous (SC) or intravenous (IV) injectionand the dose administered (dose volume) is adjusted based on subjectweight on a mg/kg basis. This is achieved using a set of fixed dosesaligned to a set of weight brackets. In total, human dosing supports abroad weight range of 43 to 109 kg. Subjects who present with a higherbody weight (>109 kg) are accommodated on a case-by-case basis, inconsultation with a medical monitor.

R5000 is stored at 2° C. to 8° C. [36° to 46° F.]. Once dispensed tosubjects, R5000 is stored at controlled room temperature (20° C. to 25°C. [68° F. to 77° F.]) for up to 30 days, and is protected from sourcesof excessive temperature fluctuations such as high heat or exposure tolight. Storage of R5000 outside of room temperatures is preferablyavoided. R5000 may be stored for up to 30 days under these conditions.

Example 3. Stability Testing

Stability testing is carried out according to the InternationalConference on Harmonisation (ICH) Q1A “Stability of New Drug Substancesand Products.” Samples from the aqueous solution of Example 1 are heldat 3 temperatures: −20° C., 5° C., and 25° C. Testing intervals are at1, 2, and 3 months, and thereafter every 3 months up to 24 months.Samples are tested for appearance (e.g., clarity, color, presence ofprecipitate), pH, osmolality, concentration, purity, target activity(e.g., by RBC lysis assay), particulate levels, endotoxin levels, andsterility. Samples are considered stable if, at each of the temperatureconditions tested, the samples have a clear, colorless appearance withno visible particles; a pH of 7±0.3; an osmolality of 260 to 340mOsm/kg; a purity of ≥95% (and no single impurity >3%); target activitythat is comparable to a reference standard; particulate levels of ≤6,000particulates per vial for ≥10 μm particles and levels of ≤600particulates per vial for ≥25 μm particles; endotoxin levels of ≤100EU/mL; and no microorganism growth.

Example 4. Freeze-Thaw Stability

A study was conducted to test stability of the aqueous solution ofExample 1 when exposed to multiple freezing and thawing cycles. R5000showed no degradation or other changes after 5 cycles of freezing andthawing.

Example 5. Surface Plasmon Resonance (SPR)-Based Binding Evaluation

The binding interaction between R5000 and C5 was measured using surfaceplasmon resonance. R5000 bound C5 with an equilibrium dissociationconstant (K_(D)) of 0.42 nM at 25° C. (n=3) and a K_(D) of 0.78 nM at37° C. (n=3). Overall surface plasmon resonance data, when combined withanalysis of a high-resolution co-crystal structure, indicate that R5000exhibits specific, strong and rapid association with C5 as well as aslow dissociation rate.

Example 6. Evaluation of C5 Cleavage Inhibition

R5000 was assessed for inhibition of C5 cleavage to C5a and C5b by ELISAanalysis of C5a cleavage product and C5b-9 membrane attack complex (MAC)formation. The inhibitory activity of R5000 with host C5 is an importantfactor in choosing appropriate animal models for drug safety. Theinhibition of C5 cleavage is the basis for the clinical efficacy foreculizumab, currently the only approved therapy for the treatment ofPNH. R5000 demonstrated a dose-dependent inhibition of C5a formationfollowing activation of the Classical Pathway (IC₅₀=4.8 nM; FIG. 1) anda dose dependent inhibition of C5b (as measured by C5b-9 or MACformation) upon activation of the Classical and Alternative complementpathways (IC₅₀=5.1 nM; FIG. 2).

Example 7. Inhibition of Complement-Induced Red Blood Cell (RBC)Hemolysis

The RBC lysis assay is a reliable method to screen complement inhibitorsin sera/plasma from various species and compare relative activities ofthe test article. An m vitro functional assay was used in order toassess the inhibitory activity of peptides, including R5000, againstcomplement function in several species. This assay tests the functionalcapability of complement components of the classical pathway to lysesheep RBCs pre-coated with rabbit anti-sheep RBC antibodies. Whenantibody-coated RBCs are incubated with test serum, the classicalpathway of complement is activated and hemolysis results and ismonitored by release of hemoglobin. Antibody-sensitized sheep red bloodcells were used as the vehicle for lysis in this assay and the seraand/or plasma from various species were used at their predetermined 50%hemolytic complement activity (CH₅₀).

R5000 demonstrated potent inhibition of complement-induced RBC hemolysisin the serum and/or plasma of human, non-human primates, and pigs (seeTable 1).

TABLE 1 Inhibition of red blood cell hemolysis by R5000 in multiplespecies Species IC₅₀ (nM) Human 6.6 Non-human primate (4 species) 3.5 to17.6 Dog >4700 Rabbit >67000 Porcine (2 species) 51.9 to 118.6 Rodents(3 species)   591 to >100000

Weak activity was observed in rat plasma (>100 times lower thanCynomolgus monkey) and little to no activity was seen in other rodents,dog, or rabbit. Structural data obtained from a co-crystallization ofhuman C5 with a molecule closely related to R5000 provided anexplanation for this species selectivity through a careful analysis ofthe primary amino acid sequence at the drug-binding site of the targetprotein. While primate sequences are 100% conserved within residuesresponsible for R5000 interactions, there were significant differencesin these residues in rodents and particularly in dog where identicalportions of the protein do not exist. These amino acid differences weresufficient to explain the activity profiles of R5000 in differentspecies.

The ability of R5000 to inhibit complement-mediated lysis oferythrocytes via the classical and alternative complement activationpathways was also tested. The classical pathway was evaluated using twodifferent assays utilizing antibody-sensitized sheep erythrocytes. Inone method, hemolysis was evaluated using 1% normal human serum, whilethe second assay utilized 1.5% C5-depleted human sera containing 0.5 nMhuman C5. The inhibition of the alternative complement activationpathway was evaluated using rabbit erythrocytes in 6% normal human serumin the absence of calcium (see Table 2).

TABLE 2 Inhibition of hemolysis by R5000 in complement activationpathways Pathway IC₅₀ Classical pathway 4.9 C5-depleted sera -classicalpathway 2.4 Alternative pathway 59.2

R5000 demonstrated complement mediated lysis in both, the classicalpathway assays and the alternative pathway assay.

Example 8. Pharmacodynamics in Cynomolgus Monkeys

R5000 is a potent inhibitor of complement in primates, thus Cynomolgusmonkeys were selected for multi-dose studies to evaluate the inhibitoryactivity of R5000 in an animal model. Plasma drug concentrations weredetermined by LC-MS and complement activity was assayed using the RBClysis assay described previously. Overall results from these studiesindicated that plasma drug levels should be at or greater than 2.5 μg/mLin monkeys to achieve >90% inhibition of complement activity (see FIG.3).

R5000 was administered to Cynomolgus monkeys at multiple daily dosesthrough subcutaneous injections (SC) in a 7-day study. Blood sampleswere analyzed for hemolysis as an indicator of complement activity atthe indicated time points (for days 1, 4, and 7, data are reported asdays after first dose, but prior to dosing on the respective day) usingan ex vivo sheep RBC lysis assay with 1% plasma in the assay. Druglevels were determined from the same sample using an LC-MS methodspecific for R5000. As shown in Table 3 and in FIG. 4 and FIG. 5, whenR5000 was administered daily for 7 days at either 0.21 or 4.2 mg/kg,minimal (<3% of pre-dose) complement activity was seen throughout thedosing period.

TABLE 3 Mean pharmacodynamic values # of Daily Last point % HemolysisAnimals Dose collected Day Day Day Day Day Day Day dosed (mg/kg) Route(days) 1 4 7 8 12 14 18 2 0.21 SC 18 2.9 1.9 2.4 5.4 75.4 >95 >95 2 4.2SC 18 <1 <1 <1 1.1 8.7 45.7 87.3

Hemolysis in the ex vivo assay was maintained below 90% of baselineafter the first dose in the 0.21 mg/kg group, throughout the dosingperiod, and up to 24 hours after the last dose. Increasing levels ofhemolysis were seen after treatment was discontinued. By Day 4 (264hours in FIG. 4) after the last dose was administered, hemolysiswas >75% of baseline. This correlates well with the measured plasmalevels for the compound during and after dosing (dotted line in FIG. 4).The second group of animals in the multi-dose study was administereddaily 4.2 mg/kg doses of R5000. In this group, hemolysis was essentiallycompletely inhibited (at <1%) throughout dosing and remained below 3% at48 hours after the last dose (Day 9: 216 hours in FIG. 5). Four daysafter the final dose (264 hours in FIG. 5), hemolysis reachedapproximately 10% of baseline. This result again demonstratedsuppression of complement activity throughout the dosing period (ascompared to pre-dose results) correlating with plasma drugconcentrations and demonstrated an excellent correlation betweenpharmacokinetic and pharmacodynamic values.

The complement inhibitory activity of R5000 was assessed in a 28day-repeated-dose study in Cynomolgus monkey using the ex vivo RBChemolysis assay. R5000 was administered daily via subcutaneous injectionfor 28 days at either 0, 1, 2, or 4 mg/kg/day (Day 1: FIG. 6 and Day 28:FIG. 7). Results demonstrated complete inhibition of hemolysis from 2hours after administration of the first dose through 28 days of dosing,with hemolysis percentages of <5% in 1, 2, and 4 mg/kg/day groups,compared to >90% in the control group. After a 28-day recovery period,sample values returned to nearly baseline hemolysis levels and little tono inhibition of the complement system was observed. The absence ofcomplement inhibition activity at the end of the recovery periodindicated clearance of the drug from the animals.

Complement inhibition was also tested as part of a 13 week-repeated-dosestudy in the Cynomolgus monkey. Monkey samples were analyzed using theex vivo RBC hemolysis assay. R5000 was administered daily viasubcutaneous injection for 13 weeks at either 0, 0.25, 1, 2, or 10mg/kg/day doses. Similar to the 28-day study, results from the 13-weekstudy demonstrated complete inhibition of hemolysis ex vivo from 2 hoursafter administration of the first dose through 13 weeks of dosing, withhemolysis percentages of <5% in 0.25, 1, 2, and 10 mg/kg/day groups,compared to >90% in the control group. After a 28-day recovery period,sample values returned to nearly baseline hemolysis levels and little tono inhibition of the complement system was observed. The absence ofcomplement inhibition activity at the end of the recovery periodindicated clearance of the drug from the animals.

During the study, oxidative metabolism resulted in the formation anddetection of a hydroxylated metabolite of R5000 with ω-hydroxylation ofthe palmitoyl tail (referred to herein as “R5001”).

The ability of R5001 to inhibit complement-mediated lysis oferythrocytes via the classical complement activation pathways was testedusing antibody-sensitized sheep erythrocytes in 1% normal human serum.R5001 demonstrated potent inhibition of complement-induced hemolysiswith an IC₅₀ of 4.5 nM.

Example 9. Pharmacokinetic/Pharmacodynamic Modeling and Simulation ofHuman Pharmacokinetics

A PK/PD model was constructed in silico using in vivo data obtained inCynomolgus monkeys. The model fit and accuracy were estimated bycomparing simulated results to newly generated experimental data. Oncevalidated in monkeys, the final model was used to predict humanpharmacokinetics by applying allometric scaling to its parameters. Theresulting simulations support a projected dosing interval of once dailyor less frequently in humans, with daily doses of 0.1 mg/kg maintainingnearly 90% target inhibition at steady state (see FIG. 8). Because ofthe long half-life of R5000, several doses are necessary to reach finalpeak and trough drug levels. The plasma C_(max) is expected to beapproximately 3-fold higher following one week of daily dosing than thefirst dose as drug levels reach steady state.

Example 10. Phase 1 Single-Ascending-Dose Clinical Study of R5000

A Phase 1 single-ascending-dose clinical pharmacology study in healthyhuman volunteers designed to evaluate the safety, tolerability,pharmacokinetics and pharmacodynamics of R5000 following subcutaneous(SC) injection was carried out. Dose volume was determined by the doserequirements of the cohort and the weight of the subject. Subjects thatwere pregnant or nursing as well as any subjects with systemic infectionor colonization with Neisseria meningitides were excluded. The study wasrandomized, double-blinded, and placebo (PBO)-controlled with 4 SCsingle-ascending-dose cohorts housed in a clinical pharmacology unit for3 days. All subjects received prophylaxis with ciprofloxacin, andsubjects in the highest single-dose cohort (i.e. 0.4 mg/kg) werevaccinated against Neisseria meningitides at least 14 days prior to thestudy. All subjects received 1 dose of R5000 on Day 1. Four subjects (2receiving R5000 and 2 receiving PBO) were administered the lowest doselevel (0.05 mg/kg) and 6 subjects per cohort (4 receiving R5000 and 2receiving PBO) were sequentially administered the 3 higher dose levels(0.1, 0.2, and 0.4 mg/kg). Subject demographic information is providedin Table 4.

TABLE 4 Subject demographics R5000 R5000 R5000 R5000 Placebo treated,treated, treated, treated, treated, 0.05 mg/kg, 0.1 mg/kg, 0.2 mg/kg,0.4 mg/kg, All, n = 8 n = 2 n = 4 n = 4 n = 4 n = 22 Male:Female ratio2:6 0:2 0:4 0:4 1:3 3:19 Mean Age, 39 23 27 34 32 33 years (min, max)(20, 59) (22, 23) (20, 37) (22, 65) (21, 58) (20, 65) Mean body mass 2420 21 26 27 24 index, kg/m2 White:Black:Asian 7:1:0 2:0:0 2:1:1 3:0:14:0:0 18:2:2

Safety was assessed by intensive clinical monitoring, and frequent bloodsamples were obtained for determination of R5000 concentrations byliquid chromatography/high resolution mass spectroscopy and ability toinhibit complement-mediated RBC lysis in an ex vivo antibody-sensitizedsheep erythrocyte hemolysis assay.

The pharmacokinetic (PK) parameters measured in this study includeclearance (CL), C_(max) (maximum plasma drug concentration, FIG. 9A),T_(max) (time taken to reach maximum plasma concentration following drugadministration), t_(1/2) (half-life), AUC₀₋₂₄ (area under the plasmaconcentration-time curve from time zero to 24 hours; see FIG. 9B forplasma concentration over time), AUC_(0-inf) (area under the plasmaconcentration-time curve from time zero to infinity; see FIG. 9B forplasma concentration over time), V_(z) (apparent volume of distributionduring terminal phase), K (elimination rate), and F (fractions). Resultsfor each parameter are presented in Table 5.

TABLE 5 Pharmacokinetic parameters R5000 R5000 R5000 R5000 (0.05 mg/kg)(0.10 mg/kg) (0.20 mg/kg) (0.40 mg/kg) PK Parameter Statistic N = 2 N =4 N = 4 N = 4 C_(max) Mean 1010 (14.142) 1550 (197.82) 2970 (317.80)5873 (440.71) (ng/mL) (SD) T_(max) Median 4.5 (3, 6) 3.0 (3, 24) 4.5 (3,48) 4.6 (3, 6) (h) (min, max) AUC₀₋₂₄ Mean 21440 (1020.9) 33230 (4605.6)60350 (4624.8) 112300 (8623.2) (ng*h/mL) (SD) AUC_(0-last) Mean 179800(3214.7) 375400 (47513) 655100 (113710) 822600 (120760) (ng*h/mL) (SD)AUC_(0-inf) Mean 190700 (3081.0) 408600 (52716) 702900 (143630) 863200(134870) (ng*h/mL) (SD) t_(1/2) Mean 163.5 (10.9) 185.4 (6.4) 172.0(24.8) 155.6 (14.3) (h) (SD) K_(el) (l/h) Mean 0.004248 (0.000283)0.003743 (0.000128) 0.004092 (0.00058001) 0.004482 (0.00041984) (SD)CL/F Mean 0.2622 (0.0042) 0.2481 (0.0353) 0.2933 (0.0574) 0.4711(0.0660) (mL/h/kg) (SD) V_(Z)/F Mean 61.89 (5.13) 66.41 (10.20) 71.43(7.52) 105.10 (11.68) (mL/kg) (SD)

All cohorts achieved C_(max) levels consistent with predicted valuesfrom an in silico PK model generated using data from non-human primate(NHP) studies. Plasma concentrations of a single SC injection showed alinear relationship between C_(max) and dose level (FIG. 9A) anddose-dependent exposure across all dose levels was confirmed (FIG. 9B).The mean maximum plasma concentration (C_(max)) ranged from 1010 to 5873ng/mL across doses. The mean area under the concentration-time curvefrom time 0 to 24 hours post dose (AUC-24) ranged from 21.440 to 112,300ng*h/mL across doses. These results indicate that with increasing R5000dose, there is an approximately proportional increase in plasmaconcentration (C_(max)) and exposure (AUC₀₋₂₄). The median time tomaximum observed plasma concentration (t_(max)) ranged from 3.0 to 4.6hours across doses indicating R5000 exhibits an intermediate rate ofabsorption from the SC space to the central (blood) compartment. Themean apparent total body clearance (CL/F) after R5000 administration waslow and ranged from 0.2481 to 0.4711 mL/h/kg. The mean half-life(t_(1/2)) was consistent across dose levels and ranged from 155.6 to185.4 hours. The mean apparent total volume of distribution (V_(z)/F) atthe terminal phase after extravascular administration ranged from 61.89to 105.1 mL/kg which indicates R5000 is localized primarily in thecirculating blood compartment with minimal extravascular distribution.The approximate t_(1/2) across all cohorts was determined to be 7 days.

R5000 also exhibited a rapid dose-dependent inhibition of hemolysis[direct hemolysis (FIG. 10A) and % CH₅₀ (FIG. 10B) and red blood celllysis at 1% plasma over time (FIG. 10C)] and suppression of complementactivity (as determined by WIESLAB® ELISA in all subjects after a singledose, see FIG. 11). The maximum pharmacodynamics effect was observedapproximately 3 hours after dosing. Results demonstrated that at themaximum plasma concentration, the maximal percent inhibition ofhemolysis compared to baseline reached >90% for the 0.1, 0.2, and 0.4mg/kg dose cohorts and 60% for the lowest dose (0.05 mg/kg) cohort.Dose-dependent inhibition of hemolysis of up to 4 days was observed forthe 0.1, 0.2, and 0.4 mg/kg dose cohorts. Notably, mean hemolysisremained above baseline for up to 2 days in the 0.05 mg/kg cohort, up to4 days in the 0.1 mg/kg cohort, and for up to 7 days in the 0.2 and 0.4mg/kg cohorts.

Similarly, analysis of complement activity demonstrated that inhibitionof complement activity remained strong over the course of 4 daysfollowing the 0.4 mg/kg injection (see FIG. 11). Human plasma samplestaken from subjects receiving 0.4 mg/kg injection were subjected toWIESLAB® ELISA (Euro Diagnostica, Malmo, Sweden) analysis. This assaymeasures the alternative pathway of complement activity. As measured viathis assay, complement activity was suppressed to 3% at 3 hoursfollowing dosing and remained below 13% 96 hours after receiving R5000.

Single SC doses of R5000 were safe and well tolerated in healthyvolunteers. No clinically significant changes were observed in vitalsigns, clinical laboratory parameters, physical exams, and ECGs.

This study suggests that low daily doses may achieve steady-state levelssuitable for >80% suppression of hemolysis and that once-weekly dosingmay be sufficient. Specifically, 0.2 mg/kg may result in fullsuppression of complement activity and complete inhibition of hemolysis.

Example 11. Multiple-Dose Clinical Study of R5000

A Phase 1 multiple-dose clinical pharmacology study in healthy humanvolunteers designed to evaluate the safety, tolerability,pharmacokinetics and pharmacokinetics and pharmacodynamics of R5000following once daily subcutaneous (SC) injections over 7 was carriedout. The study was single-center, randomized, double-blinded, andplacebo (PBO)-controlled. Subjects received daily SC doses of 0.2 mg/kgR5000 or matching PBO for 7 days while housed in a clinical pharmacologyunit. Dose volume was determined by the dose requirements of the cohortand the weight of the subject. Subjects that were pregnant or nursing aswell as any subjects with systemic infection or colonization withNeisseria meningitides were excluded. All subjects received prophylaxiswith ciprofloxacin, and subjects in the multiple-dose cohort werevaccinated against Neisseria meningitides at least 14 days prior to thestudy. Safety was assessed by intensive clinical monitoring and dailyblood samples were obtained immediately prior to dosing as well as, 3hours, and 6 hours after each day's dose for determination of R5000concentrations by liquid chromatography/high resolution massspectroscopy and ability to inhibit complement-mediated RBC lysis in anex vivo antibody-sensitized sheep erythrocyte hemolysis assay.

A total of 6 subjects were enrolled into the study (4 receiving R5000and 2 receiving PBO). Subject demographics are presented in the Table 6.

TABLE 6 Subject demographics Placebo treated, R5000 treated, n = 2 n = 4Male:Female ratio 0:2 1:3 Mean Age, years (min, max) 27 (25, 29) 24 (22,26) Mean body mass index, kg/m² 21 23 White:Asian 2:0 3:1

As seen in Table 7 and related FIG. 12A (demonstrating percent hemolysisand plasma concentration over 7 days), plasma concentrations showed asteadily increasing exposure over the 7 days of dosing. From these data,the half-life of R5000 was determined to be 7 days. Plasma levelsreturned to around 2000 ng/ml by day 15 and around 1000 ng/ml by day 21(FIG. 12B).

TABLE 7 Plasma concentrations of R5000 Time Point Concentration of R5000(ng/ml) (hrs) Subject 1 Subject 2 Subject 3 Subject 4 0 0 0 0 0 3 25102410 2560 2520 6 2300 2390 2410 2650 24 1890 1750 1810 2220 27 3870 40504280 4110 30 3650 3730 4310 4000 48 2910 2650 3370 3330 51 5200 49105330 5500 54 4820 4220 5100 4900 72 3680 3340 3780 4460 75 6310 52405280 6110 78 5720 5570 5880 6140 96 4650 3790 4840 4540 99 6660 53206860 6770 102 7000 5440 6550 6820 120 4840 4430 5200 5280 123 7210 64107210 7700 126 7290 5850 6880 7020 144 5170 4210 4920 5430 147 7430 63207490 7780 150 6920 6130 7630 7110 168 5750 4940 5730 5670

The PK parameters of R5000 following multiple dose SC administration(0.2 mg/kg/day) for 7-days are presented in Table 8. The pharmacokinetic(PK) parameters measured include clearance (CL), C_(max) (maximum plasmadrug concentration), T_(max) (time taken to reach maximum plasmaconcentration following drug administration), t_(1/2) (half-life),AUC_(tau) (area under the plasma concentration-time curve from time zeroto 24 hours), AUC_(0-inf) (area under the plasma concentration-timecurve from time zero to infinity), V_(z)/F (apparent volume ofdistribution), K_(el) (elimination rate), and F (fractions).

TABLE 8 Summary of PK parameters R5000 (0.20 mg/kg) (N = 4) PK ParameterStatistic Day 1 Day 7 Cmax Mean 2533 (100.1) 7290 (662.4) (ng/mL) (SD)T_(max) Median 3 (3, 6) 3 (3, 6) (h) (min, max) AUC_(tau) Mean 50010(3334.0) 151300 (12042) (ng*h/mL) (SD) AUC0-inf Mean NC 1101000 (108220)(ng*h/mL) (SD) t_(1/2) Mean NC 161.9 (14.8) (h) (SD) K_(el) (1/h) MeanNC 0.004309 (0.00041325) (SD) CL/F Mean NC 1.330 (0.114) (mL/h/kg) (SD)V_(Z)/F Mean NC 311.6 (51.4) (mL/kg) (SD)

The day 1 mean C_(max) and AUC_(tau) were 2533 ng/mL and 50,010 ng*h/mLrespectively, consistent with results from the 0.2 mg/kg single-dosecohort over the same post-dose period. Following daily SC administrationfor 7 days, the C_(max) and AUC_(tau) increased by approximately2.9-fold (mean day 7 C_(max)=7290 ng/mL) and 3.0-fold (mean day 7AUC_(tau)=151,300 ng*h/mL) respectively. The median time to maximumplasma concentration (Tax) on day 7 was 3.0 hours, which was consistentwith the T_(max) following single dose SC administration (median day 1T_(max)=3.0-4.6 hours). This indicates a consistent rate of R5000absorption with repeat dosing. The mean day 7 apparent total bodyclearance of R5000 (day 7 CL/F=1.3 mL/h/kg) was slightly increasedrelative to the total body clearance following a single SC dose at 0.2mg/kg [single ascending dose (SAD) 0.2 mg/kg CL/F=0.29 mL/h/kg].However, the elimination rate constant (K_(el)) for R5000 was consistentfollowing single and repeat dosing (0.2 mg/kg SAD mean K_(el)=0.0041h⁻¹; 0.2 mg/kg MD mean day 7 K_(el)=0.0043 h⁻¹) indicating that theclearance of R5000 does not change significantly with repeat dosing. Theapparent volume of distribution of R5000 (V_(z)/F) showed some increasewith administration of multiple doses of R5000 (0.2 mg/kg SAD meanV_(z)/F=71.4 mL/kg, 0.2 mg/kg MD mean day 7 V_(z)/F=311.6 mL/kg).However, the day 7 V_(z)/F for R5000 was still less than total bodywater suggesting that R5000 did not distribute into the extravascularspace upon repeat SC administration.

Mean percent inhibition of hemolysis was measured in subject serumsamples to determine whether low daily doses are suitable to achievesteady-state levels and complete and sustained inhibition of complementand suppression of hemolysis (see Table 9).

TABLE 9 Hemolysis analysis Time Point % Hemolysis (treated) % Hemolysis(placebo) (hrs) Subject 1 Subject 2 Subject 3 Subject 4 Subject 5Subject 6 0 100.0 100.0 100.0 100.0 100.0 100.0 3 5.8 1.9 5.0 2.9 99.4102.7 6 6.0 1.6 5.2 2.3 90.8 99.4 24 9.3 2.4 8.9 2.9 105.8 100.7 27 4.91.2 4.0 1.0 112.3 96.1 30 4.6 1.5 4.6 2.2 110.5 100.6 48 6.6 2.0 6.9 2.1120.6 107.2 51 4.0 1.4 3.6 1.9 118.4 97.3 54 3.7 1.4 3.6 1.8 133.5 98.072 5.0 1.6 3.8 1.7 114.4 97.9 75 2.9 0.8 2.7 1.3 121.4 98.2 78 3.0 0.94.7 1.5 119.4 94.6 96 3.9 1.1 4.0 6.5 111.5 95.2 99 2.9 0.9 2.7 1.0122.0 101.1 102 3.6 1.4 3.8 1.7 135.1 101.4 120 4.0 2.1 3.8 2.3 115.495.7 123 2.7 1.3 2.7 1.6 114.1 92.2 126 3.3 1.3 3.2 1.3 113.5 96.9 1443.4 1.2 3.8 1.4 108.8 95.7 147 2.5 1.2 2.6 1.2 121.7 103.7 150 3.4 1.33.0 1.4 121.3 98.3 168 3.4 1.5 3.1 1.8 119.1 102.0

Mean percent inhibition of hemolysis compared to baseline reached ≥95%beginning at the first time point following dosing, 3 hours after dosingon Day 1, and continued throughout the 7 days of dosing. All individualsubjects showed ≥90% reduction of hemolysis at all time points.Hemolysis at day 8 (24 hours after receiving the last dose) was observedto be ≤3% in all subjects. Hemolysis returned to pre-dose levels withintwo weeks following the last dose.

The study suggests that low daily doses will achieve steady-state levelssuitable for complete and sustained inhibition of complement andsuppression of hemolysis. The study also suggests that once-weeklydosing may be sufficient to inhibit complement activity and reducehemolysis in humans.

Complement activity in subject plasma samples was determined by WIESLAB®ELISA (Euro Diagnostica, Malmo, Sweden) analysis. This assay measuresthe alternative pathway of complement activation. As measured via thisassay, suppression of complement activity was rapid, complete, andsustained across the dosing period in all subjects (see FIG. 13A andTable 10). In the Table, SEM indicates standard error of the mean.

TABLE 10 % complement activity in multiple dose study Hours after firsttreatment 3 48 96 Minimum % complement 1.8 (0.8) 6.9 (0.3) 2.1 (0.1)activity (SEM) Average % complement 3.1 (0.6) 8.2 (1.1) 3.1 (0.8)activity (SEM)

Complement activity at day 8 (24 hours after the last dose) was observedto be ≤5% in all subjects. Complement activity returned to pre-doselevels within two weeks following the last dose (FIG. 13B).

R5000 was safe and well-tolerated in healthy volunteers. No clinicallysignificant changes were observed in vital signs, clinical laboratoryparameters (hematology, blood chemistry, coagulation, and urinalysis),physical exams and ECGs.

R5000 and metabolite R5001 were measured in the 0.20 mg/kg dose group ofthe multi-dose arm of the study, and both were detected.

Example 12. Pharmacokinetic/Pharmacodynamic Modeling and Simulation ofHuman Pharmacokinetics for Phase II Study

A PK/PD model was developed to describe plasma concentrations of R5000and its metabolites, and their activity in an ex vivo red blood celllysis assay. The model was based on a quasi-steady-state approximationof the target-mediated drug disposition model. In the multi-dose arm ofthe Phase I study with R5000, all subjects achieved drug levelsconsistent with predicted values from the in silico PK model generatedusing single-dose human PK and PD data. Human PK/PD simulations of R5000support a projected dosing regimen of a 0.3 mg/kg loading dose followedby daily doses of 0.1 mg/kg yielding ≥90% target inhibition after thefirst dose and at steady state (FIG. 14).

Example 13. Phase II Clinical Trial Study Design

A 0.1 mg/kg/day dose of R5000 was selected based on the predicted steadystate drug levels for the nominal as well as the maximum dose (based onweight bracketing). Results are presented in Table 11. In the Table,C_(max) refers to maximum plasma drug concentration, AUC₀₋₂₄ indicatesarea under the plasma concentration-time curve from time zero to 24hours, SD indicates single dose, QD indicates once daily dose, and *adjacent to maximum dose indicates the potential maximum dose receivedby patients due to weight bracketed dosing.

TABLE 11 Experimental and predicted PK values R5000 R5000 (0.1 mg/kg)Steady State (0.2 mg/kg) Prediction in Human QDx7; Day Nominal (Minimal)Maximum dose* Pharmacokinetic 7 Human 0.1 mg/kg once 0.14 mg/kg onceParameter Statistic (SD) daily daily C_(max) (μg/mL) Mean 7.29 (0.66)6.57 7.12 AUC₀₋₂₄ Mean 151.3 (12) 141.5 152.8 (h*μg/mL)

The inhibition of hemolysis was expected to be maintained at ≥90% at alltimes with a daily dose of 0.1 mg/kg R5000 and a loading dose of 0.3mg/kg R5000 administered on the first day of dosing based on Phase Istudies. This prediction was supported by overlaying the expected R5000plasma concentrations at steady state, with the PK/PD relationshipobtained from Phase 1 studies in healthy volunteers (FIG. 15). Adequateand sustained control of hemolysis is a key component of both efficacyand safety in treating paroxysmal nocturnal hemoglobinuria (PNH). Inthis disease, even a modest transient decrease in complement blockadecan lead to immediate “breakthrough” intravascular hemolysis andrecrudescence of severe PNH symptoms. This consideration wasparticularly important with respect to accounting for the potential formissed doses.

In order to achieve and maintain hemolysis control efficiently, thePhase 2 studies were designed to incorporate a single loading dose of0.3 mg/kg to adequately suppress hemolysis after the first dose. Welltolerated single doses of up to 0.4 mg/kg sub cutaneous injections inthe single dose cohorts of the Phase 1 study in healthy volunteers (FIG.16A) provided the rationale for the use of a 0.3 mg/kg loading doseafter overlaying the expected R5000 plasma trough concentrations afterthe first dose, with the PK/PD relationship obtained from Phase 1studies in healthy volunteers. The loading dose was not expected toimpact expected exposures at steady state. A loading dose of 0.3 mg/kgwas predicted to achieve the target pharmacodynamic effect (>90%hemolysis inhibition) at trough levels, to facilitate immediate controlof hemolysis after the first dose (see the PK/PD model presented in FIG.16B). Based on the PK/PD model, if, after reaching steady state asubject misses a dose, the proposed starting dose regimen was expectedto maintain inhibition of hemolysis at ≥90% for at least 72 hours (seethe model presented in FIG. 16C).

From the Week 2 visit onwards, subjects not achieving an adequateresponse (defined as a lactate dehydrogenase level that is 1.5 timesless than the upper limit normal), and following evaluation of safetyand tolerability data by the investigator and the medical monitor, thedose was planned to be escalated to 0.3 mg/kg daily. The dose wasplanned to be escalated to 0.3 mg/kg daily if an overt breakthroughhemolysis episode (e.g., hemoglobinuria) was observed.

Example 14, Phase II Study Dose. Administration and Contraindications

During Phase II clinical studies, R5000 is administered once daily(every 24 hours) by SC self administration at a dose of 0.1 mg/kgfollowing an initial loading dose of 0.3 mg/kg on the first day ofdosing (Study Day 1). Some subjects may receive a higher dose of 0.3mg/kg to optimize control of hemolysis. The dose (dose volume) for eachinjection is determined based on the dose assigned and patient bodyweight. It is not anticipated that overdose of R5000 will lead to acuteor specific systemic adverse events. In case of overdose, clinicallyappropriate supportive measures are instituted as determined by theclinical scenario, and in consultation with a medical monitor.

R5000 daily dosing has the potential to achieve consistent and sustainedinhibition of complement, and therefore reduce the risk of breakthroughhemolysis. The dosing regimen of R5000 is selected to avoid a large peakto trough ratio in plasma concentration, as is seen with monoclonalantibodies administered every two weeks. With an approximate plasmahalf-life of 7 days, R5000 administered daily is expected to remainwithin a narrow plasma concentration range, effectively “clamping”terminal complement activity under continuous inhibition and avoidingthe phenomenon of “breakthrough hemolysis”.

This is in contrast to the current standard of care, eculizumab. Aproportion of patients receiving eculizumab are reported to haveinadequate control of their disease which results in breakthroughhemolysis occurring near the end of the 2-week dosing interval using theapproved dose of 900 mg biweekly (Hillmen P, et al. Long-term safety andefficacy of sustained eculizumab treatment in patients with paroxysmalnocturnal haemoglobinuria. Br J Haematol 2013; 162:62-73 and Brodsky RA. Paroxysmal nocturnal hemoglobinuria. Blood 2014; 124:2804-2811). Theclinically approved treatment schedule of eculizumab is biweekly. i.e.once every 12-16 days. While hemolysis is well controlled within thefirst days of the treatment cycle, efficacy is often reduced, as plasmalevels of eculizumab fade in the last days before re-administration.This lack of disease control while on eculizumab has resulted in a needto increase doses above the authorized dose, for which no clinicaltrials have been performed to establish safety or efficacy. The UnitedKingdom (UK) PNH National Service Reports shows that nearly 22% ofpatients treated with eculizumab require non-standard doses due tobreakthrough hemolysis at the standard dose.

Subjects are instructed to self-administer SC doses daily every 24 hoursat approximately the same time each day. Subjects are directed to injectin the abdomen, however injections to the thigh or upper arm may beused. In the study, subjects are required to document daily confirmationof dosing and the location of the injection. The currently availabletherapy, eculizumab, requires intravenous infusions to be administeredevery 2 weeks under medical supervision. In contrast, R5000 has beendeveloped for subcutaneous self-administration at home, and thus is aconvenient therapy format for patients.

Subjects who have hypersensitivity to R5000 or any of its excipients donot receive treatment with R5000. Subjects with colonization, orunresolved or suspected infection with Neisseria meningitides are alsoprohibited from treatment with R5000.

Example 15. Safety Assessment in R5000 Phase II Clinical Trial

The clinical study includes safety assessments to monitor adverse events(including injection reactions and systemic infection), clinicallaboratory tests (including markers for liver and pancreatic function),ECG, vital signs, and physical examinations. The Phase II studiesincorporate frequent monitoring visits with clinic visits scheduledweekly for the first 4 weeks, followed by every 2 weeks thereafter. Thelong-term extension study includes continued monitoring with clinicvisits monthly for the first 3 months, and every 3 months thereafter,with monitoring and clinic visits expected to continue to accruelong-term safety and tolerability data.

Example 16. Inhibition of Hemolysis Using R5000-Related Peptides withRed Blood Cells Non-Responsive to Eculizumab Due to C5 Mutation

Blood/plasma samples from two Japanese PNH patients who had a poorresponse to eculizumab were analyzed. Both patients were previouslyshown to possess a single missense C5 heterozygous mutation, c.2654G→A,which predicts the polymorphism p.Arg885His (for a description of thispolymorphism, see Nishimura, J. et al., N Engl J Med. 2014,370(7):632-9, the contents of which are herein incorporated by referencein their entirety). In the study, mR5000 was tested on patient serumsamples. mR5000 is identical to R5000, except the C-terminal lysine isunmodified. Compound mR5000 has similar anti-hemolytic activity to thatof R5000, but a shorter half life when administered to a subject.Patient serum was acidified and mixed with RBCs in the presence (+) orabsence (−) of mR5000. Complete inhibition of hemolysis was observed inthe presence of mR5000 (FIG. 17).

Example 17. R5000 Treatment in Patients Who are not Responsive toEculizumab

Based on the distinct binding site of R5000, R5000 is used for treatmentof PNH in patients with mutations in the C5 gene that prevent binding ofeculizumab to C5. R5000 binds to a distinct site on C5 compared witheculizumab and can therefore prevent C5 activation in patients who arenon-responsive to eculizumab due to mutations near its binding site onC5.

Example 18. Comparison Between R5000 and Antibody-Based C5 Inhibitors

Inhibition of complement activity was evaluated by hemolysis of rabbitor PNH patient erythrocytes, and by measuring generation of C5a andC5b-9 by ELISA. C5 and C5-eculizumab complex levels were measured in PNHpatient samples with ELISAs using a C5-binding reagent to capture C5 orthe complex and detecting with either an anti-C5 antibody followed by anHRP-conjugated secondary antibody (total C5) or using an HRP-conjugatedsecondary to detect eculizumab (C5-eculizumab complex). Inhibition of C5binding to the alternative pathway (AP) C5 convertase was measured bySPR.

Residual hemolytic activity has been shown to exist after treatment witheculizumab (see Brodsky et al., 2017. Blood 129; 922-923 and Harder etal., 2017. Blood. 129:970-980). R5000 completely inhibited complementactivity in several in vitro assays where residual hemolysis was evidentwith eculizumab (Alexion Pharmaceuticals, New Haven, Conn.), includinghemolytic activity and generation of C5a and C5b-9. In serum from a PNHpatient treated with eculizumab, approximately 30% of the hemolyticactivity of normal human serum was retained in a rabbit erythrocytelysis assay even with the addition of excess eculizumab (up to 12.5 μM).Addition of R5000 completely abolished this residual hemolytic activity.Finally, R5000 completely inhibited C5 binding to the AP C5 convertase,as determined by SPR, while eculizumab only partially inhibited C5binding. Overall, these results suggest that the mechanism of inhibitionof R5000 promotes complete inhibition of hemolysis under conditionswhere eculizumab yields partial inhibition.

Example 19. Cohort a Results in Two Patients at Week 7

A dose-finding study to evaluate the safety, tolerability, preliminaryefficacy, pharmacokinetics, and pharmacodynamics of R5000 was carriedout in patients with PNH. The study was an open-label 12 week study withlong-term extension. The study program was conducted globally anddesigned to address 3 PNH populations: (Cohort A) eculizumab naïvesubjects; (Cohort B) subjects being switched from eculizumab to R5000;and (Cohort C) subjects with inadequate response to eculizumab. Patientsreceived R5000 by subcutaneous injection with a loading dose of 0.3mg/kg on Day 1 followed by a daily dose of 0.1 mg/kg for the first twoweeks. From the week 2 visit onward, where the lactate dehydrogenase(LDH) level was equal to or greater than 1.5 times the upper limitnormal, the daily dose could be increased to 0.3 mg/kg. A primaryefficacy endpoint of the study was to achieve a change in LDH level frombaseline to the mean level from week 6 to week 12 of the study.

Near-complete inhibition of hemolytic activity at week 7 was achieved intwo patients (patient 001 and patient 002) in Cohort A with 100%compliance (no dosing interruptions, monitored remotely using a remotemonitoring device) with the treatment regimen. Percent hemolysis andhemoglobin levels at each time point are shown in FIG. 18A and FIG. 18B,respectively. Patient 001 was a 56-year old female diagnosed with PNH inApril of 2007. Patient 001 had a granulocyte clone size of 80% and anRBC clone size of 25% and received no transfusions prior to enrollment.Patient 002 was a 65-year old female diagnosed with PNH in April of2017. Patient 002 had a granulocyte clone size of 99% and an RBC clonesize of 47%. Patient 002 was transfusion-dependent prior to enrollmentand received transfusion at weeks 4 and 6 of the study. Rapid declinesin LDH were observed in both patients and mean LDH at week 7 was 1.55times the upper limit normal (FIG. 18C). R5000 levels remainedrelatively stable through week 6 (FIG. 18D). One transient episode ofbreakthrough hemolysis associated with inter-current illness wasobserved. No safety or tolerability concerns were identified. No seriousor related adverse events were observed and no injection site reactionswere observed.

Example 20. Surface Plasmon Resonance (SPR) Measurement of C5 InhibitorBinding

Binding of R5000 and eculizumab to alternative pathway C5-convertase wasexamined by Surface Plasmon Resonance (SPR) analysis. SPR measurementswere performed at 25° C. on a ProteOn XPR36 SPR station (Bio-Rad,Hercules, Calif.). Eculizumab was immobilized at pH 4.5 of 10 mM sodiumacetate to a Bio-Rad GLH sensor chip via amine coupling (NHS/EDCcoupling kit from Bio-Rad) and blocked with ethanolamine (Bio-Rad) at25° C. Biotinylated R5000 was separately captured to a Bio-Rad NLCsensor chip. Kinetic/affinity data of C5 binding for Eculizumab andR5000 were separately performed by flowing serial diluted C5 (ComplementTechnologies, TX) to the surfaces of eculizumab or R5000. The samerunning/assay buffer (10 mM potassium phosphate pH 7.4 and 6.0, 150 mMNaCl, 1% DMSO, and 0.01% Surfactant P-20) were used throughout. Surfaceregeneration was achieved using one injection of 10 mM Glycine (pH 1.5)followed by flowing of the running buffer. Data analysis (affinity andkinetic parameters) were conducted using a 1:1 Langmuir mode.

Biotinylated human complement component C3b (Complement Technologies,TX) was prepared by mixing EZ-link maleimide-PEG2-biotin (Thermo FisherScientific, Waltham, Mass.) with C3b stock according to the provider'sprotocol. Unused biotin was separated from biotinylated C3b throughdesalting column. Biotinylated C3b was captured on a Bio-Rad NLC sensorchip according to the standard protocol. To assemble alternative pathway(AP) C5-convertase on captured C3b surface, serial injections of humancomplement components (all purchased from Complement Technologies,Tyler, Tex.) were conducted by using a co-injection mode. Theco-injection mode included a first injection of a premixed factor B (fB;150 nM) and factor D (fD; 10 nM) (25 μl/min for 60 s), followed by 500nM C3 (25 μl/min for 120 s), then C5 (400 nM) alone or mixed withserially diluted R5000 or eculizumab (25 μl/min for 60 s). Thedissociation time was 360 s. All assays were done at 37° C. in 10 mMHEPES pH 7.4, 150 mM NaCl, 1% DMSO, and 0.01% Surfactant P-20. Toquantitatively analyze C5 binding at different inhibitor concentrations,individual SPR sensorgrams after injection of C5 were normalized to thetime point of C5 injection, and fractions of SPR signal were calculated.Results demonstrated decreased binding of C5 to the AP C5-convertase inthe presence of R5000 and eculizumab (as evidenced by decreased responseto C5, see FIG. 19), with 2 μM R5000 having a stronger effect.

Example 21. Inhibition of PNH Patient Erythrocyte Hemolysis

Inhibition of hemolysis in erythrocytes from PNH patients was assessedin the presence or absence of R5000 and eculizumab. Erythrocytes werecollected from PNH patient blood samples by centrifugation at 1000×g for3 minutes to pellet, and washed 3 times with Alsever's solution. Thecell pellet was resuspended 1:2 in GVB⁺⁺ buffer (Complement Technology,Tyler, Tex.). Donor-matched normal human sera was acidified to pH 6.4 byaddition of HCl. PNH patient erythrocytes (2.5% v/v) were incubated in aclear 96-well assay plate with 50% acidified donor-matched serum andindicated concentrations of compounds for 18 hours at 37° C. Cells werethen centrifuged at 1000×g for 3 minutes and 100 μl of the supernatanttransferred to a separate clear 96-well assay plate for detection ofabsorbance at 412 nm.

The results from two patients shown in FIG. 20 and FIG. 21 respectively,demonstrate that R5000 completely blocks hemolysis of PNH patienterythrocytes, while eculizumab partially inhibits hemolysis. RecombinantC5 containing a known polymorphism p.Arg885His, which confers resistanceto eculizumab, was used as the only source of C5 in an alternativepathway hemolysis assay, using C5 depleted serum and rabbiterythrocytes. Increasing concentrations of R5000 or eculizumab weretested in the assay to evaluate their ability to inhibit hemolysis (seeFIG. 22). The results demonstrate that R5000 is capable of binding andinhibiting hemolysis mediated by C5 p.Arg885His, while eculizumab isineffective.

Example 22. Measurement of C5, Eculizumab, and C5/Eculizumab ComplexLevels in PNH Patient Plasma

C5, eculizumab and C5/eculizumab complex levels in PNH patient plasmawere measured by one of three ELISA formats, each using a variant ofR5000 as a capture agent. The R5000 assay variant included an N-terminalbiotinylated PEG moiety and substitution of the modified C-terminallysine residue with norvaline. 5 pmol per well of the R5000 variant wasimmobilized on a NeutrAvidin coated 96-well microplate (Thermo FisherScientific, Waltham, Mass.) to serve as a capture agent for C5.Immobilization was carried out in assay buffer (25 mM Tris-HCl, 150 mMNaCl, 0.05% Tween-20 and 1 mg/mL BSA) for 2 hours at room temperature,then washed 3 times with assay buffer.

For detection of total C5, plasma was diluted 1:10,000 fold in assaybuffer and 100 μL was added to assay plate wells. C5 standards wereprepared (3-fold serial dilution in assay buffer starting from 100ng/mL) and added to assay plate wells. The plate was incubated at roomtemperature for 1 hour and washed 5 times with assay buffer. Eculizumab(1 μg/mL in assay buffer) was then added to each well and incubated for1 hour at room temperature to bind any C5 in the sample that was notalready complexed with eculizumab. Horse radish peroxidase(HRP)-conjugated goat anti-human IgG (Abcam, Cambridge, UK; 1: 5000dilution) was added as a secondary antibody to detect eculizumab boundto C5 and incubated for 30 minutes at room temperature. TMB substrate(UltraTMB ELISA, Thermo Fisher Scientific) was then added to the plateand incubated for 30 minutes. The reaction was stopped with 2N sulfuricacid solution, and absorbance read on a SPECTRAMAX® M3 plate reader(Molecular Devices, Sunnyvale, Calif.) at 450 nm. The amount of total C5was calculated relative to the C5 standard curve.

Detection of C5/eculizumab complex level was performed using the samemethod as described above but without addition of excess eculizumab.This assay used diluted premixed C5/eculizumab complex (1:1 molar ratio,3-fold serial dilution starting from 100 ng/mL) as a standard.

To measure free eculizumab, 100 μl of a 1 μg/ml solution of C5 in assaybuffer was added to the assay plate coated with C5 binding peptide andincubated for 1 hour at room temperature. Patient plasma diluted1:10,000 in assay buffer was added to test wells and diluted eculizumab(3-fold serial dilution starting from 100 ng/mL) was used as a standard.

The concentration of total C5, eculizumab-bound C5, and free eculizumabdetected in samples from PNH patients treated with eculizumab or fromnormal human serum are presented in FIG. 23. These results demonstratethe presence of sufficient eculizumab in a PNH patient sample tosaturate C5 and form C5:eculizumab complexes.

Example 23, Effect of R5000 on Residual Hemolysis in Eculizumab-TreatedPNH Patient Plasma

Hemolytic activity of plasma from a patient treated with eculizumab wastested in the presence of additional eculizumab and C5 inhibitor peptide(R5000) in an assay designed to detect activation of the alternativepathway. Rabbit erythrocytes (Ers; #B302; Complement Technology Inc.,Tyler, Tex.) were incubated with 25% eculizumab-treated patient plasmain the presence of MgEGTA (B106; Complement Technology Inc., Tyler,Tex.), complement inhibitors at 12.5 μM, 4.2 μM and 1.4 μM, and assaybuffer (GVB°; #B101; Complement Technology Inc., Tyler, Tex.) for 30minutes at 37° C. in a 96-well clear assay plate. Following incubation,the plate was centrifuged at 1000×g and 100 μL of supernatant wastransferred to a new 96-well clear assay plate and the absorbance at 412nm was measured. Absorbance values were normalized to a plate control of25% (final concentration) normal human sera (#NHS; Complement TechnologyInc., Tyler, Tex.) which was set to 100% hemolysis.

Results shown in FIG. 24, suggest that even in the presence of enougheculizumab to bind to all available C5 in the patient sample, there isstill sufficient activation of the alternative complement pathway toinduce hemolysis of rabbit erythrocytes. Treatment with additionaleculizumab provided only modest inhibition of hemolysis, confirming thatthe hemolytic activity is not due to insufficient eculizumab in thesample. However, addition of R5000 completely abolished the residualhemolytic activity, demonstrating that the residual activity isC5-dependent and suggesting that R5000 can further inhibit hemolysis inthe presence of excess eculizumab.

What is claimed is:
 1. A method of treating hemolysis in a subject,wherein the subject has not been previously treated with eculizumab, themethod comprising: administering a polypeptide to the subject at aninitial loading dose, wherein the polypeptide comprises the amino acidsequence of SEQ ID NO: 1; and administering the polypeptide to thesubject at an initial treatment dose, wherein the initial treatment doseis administered two or more times at regular intervals after the initialloading dose.
 2. The method of claim 1, wherein lactate dehydrogenase(LDH) levels in the subject are monitored over the course of treatment.3. The method of claim 1, wherein the initial treatment dose issubstituted with a modified treatment dose of the polypeptide after twoweeks or more of administration with the initial treatment dose.
 4. Themethod of claim 3, wherein the modified treatment dose of thepolypeptide includes an increased dose of the polypeptide.
 5. The methodof claim 4, wherein the initial treatment dose is substituted with themodified treatment dose when subject LDH levels are equal to or lessthan 1.5 times the upper limit normal.
 6. The method of claim 1, whereinthe initial loading dose comprises from about 0.1 mg/kg to about 0.6mg/kg of the polypeptide.
 7. The method of claim 1, wherein the initialtreatment dose comprises from about 0.1 mg/kg to about 0.3 mg/kg of thepolypeptide.
 8. The method of claim 7, wherein the initial treatmentdose is substituted with a modified treatment dose of from about 0.3mg/kg to about 0.6 mg/kg of the polypeptide.
 9. The method of claim 1,wherein hemolysis in subject serum is reduced.
 10. The method of claim1, wherein at least one administration of the polypeptide comprisesself-administration.
 11. The method of claim 10, wherein theself-administration is monitored.
 12. The method of claim 11, whereinthe self-administration is remotely monitored.
 13. The method of claim11, wherein the self-administration is monitored using a smart device.14. The method of claim 1, wherein the regular intervals are from aboutevery 12 hours to about every 168 hours.
 15. The method of claim 1,wherein the subject has PNH.